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DENT655-HealthTechnologyAssessment
AHealthTechnologyAssessmentReporton:DifferentretentionsystemsusedforEndostealImplantsupportedprosthesisinpartiallyedentuloussites
by
MuraliRamamoorthia
withtheexpertassistanceof
ShahrokhEsfandiarib
April2015
ReportNo:S2015.03
aMasterscandidate,FacultyofDentistry,McGillUniversity,Montreal,CanadabAssociateProfessor,DivisionofOralHealthandSociety,FacultyofDentistry,McGillUniversity
FormoreinformationcontactDr.ShahrokhEsfandiariatshahrokh.esfandiari@mail.mcgill.ca
“The views expressed in this report are those of the author(s) and do not necessarily reflect the views of the Faculty of Dentistry, McGill University. This report was developed for the course ‘DENT 655- Health Technology Assessment’ and assumes a call from general dentists to assist decision-making in dental offices, clinical and hospitals. All are welcome to make use of it. However, to help us estimate the impact, it would be deeply appreciated if users could inform us whether it has influenced policy decisions in any way.”
Suggested citation: Ramamoorthi M & Esfandiari S. (2015). A Health Technology Assessment Report on Different retention systems used for endosteal implant supported prosthesis in partially edentulous sites (Report no: S2015.03). Montreal, Faculty of Dentistry, McGill University. Retrieved from:
https://www.mcgill.ca/dentistryohs/courses-and-events/dent-655/hta-reports
RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
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AcknowledgementsThe authors would like to acknowledge following individuals for their contributions in this
report.
Dr. Aparna Narvekar, MDS, Canada. provided her valuable assistance in search strategy,
data extraction and critical appraisal of the included studies.
These following individuals kindly provided their feedback on this report.
Dr. Amrita Kumari, BDS
Masters Candidate
Faculty of Dentistry, McGill University
Canada.
Dr. Sadaf Farookhi, BDS
Masters Candidate
Faculty of Dentistry, McGill University
Canada.
Dr. Vivek Verma, BDS, MSc
Masters Candidate
Faculty of Dentistry, McGill University
Canada.
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TableofContents
LIST OF TABLES, FIGURES, GRAPHS
GLOSSARY
EXECUTIVE SUMMARY ……………………………………………………………1-2
1. INTRODUCTION………………………………………………………………….3-8
1.1. Context 1.1.1. Partially edentulous condition 1.1.2. Epidemiology 1.1.3. Importance of treating partial Edentulism 1.1.4. Various therapeutic options 1.1.5. Rationale in choosing Implant supported prosthesis 1.1.6. Importance of retention system in implant treatment
1.2. Retention system options. 1.3. Issues
2. OBJECTIVES ……………………………………………………………………...8-9
3. METHODS………………………………………………………………………10-20 3.1. Systematic review & Meta-analysis methods
3.1.1. Literature search strategy. 3.1.2. Selection criteria and methods. 3.1.3. Data extraction strategy. 3.1.4. Critical Appraisal of included studies. 3.1.5. Data analysis & meta-analysis
methods. 3.2. Economic analysis.
3.2.1. Type of economic evaluation. 3.2.2. Model structure. 3.2.3. Data inputs. 3.2.4. Costs & Perspective 3.2.5. Assumptions.
4. RESULTS………………………………………………………………………20-50 4.1. Selection of primary studies. 4.2. Study characteristics. 4.3. Critical appraisal of included studies. 4.4. Data synthesis 4.5. Economic Evaluation
5. DISCUSSION…………………………………………………………………..50-55 5.1. Summary of clinical evidence.
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5.2. Ethical and legal considerations. 5.3. Strengths and limitations of the systematic review.
5.3.1. Strengths. 5.3.2. Limitations.
6. CONCLUSION……………………………………………………………………56
7. REFERENCES.
8. ANNEXURES.
ListofTables. 1. Therapeutic option available for managing partial edentulism
2. Comparison between single implant Vs 3 unit FPD
3. List of survival events
4. Search strategy.
5. Inclusion and exclusion criteria
6. PRISMA flow diagram.
7. Basic study characteristics of the included studies.
8. Analysis of excluded studies.
9. Analysis of included studies.
10. Results for Failure rate.
11. Results for Survival rate
12. Results for Event free rate
13. Failure rate by prosthesis and implant characteristics..
14. Survival rate by prosthesis and implant characteristics.
15. Minor and major complication events.
16. Data input in economy model.
17. Summary of results for outcome: Failure, survival
List of Figures:
1. Markov transition model.
2. Decision tree.
3. Meta – analysis [Forest plot] of failure, survival and event free effective rate using both
models.
4. ICER slopes – single crowns
5. ICER slopes- FPD.
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Acronyms&Abbreviations:
Ab- Abutment.
AAID- American Academy of
Implant Dentistry.
ACC: All Ceramic crown
CAD-CAM: Computer assisted
design/Computer aided milling.
C/CL – Cantilever FPD
Cem- Cemented
Comp- Complications
CD- Complete denture
FPD- Fixed partial denture
FDP- Fixed denture prosthesis
GPT- Glossary of Prosthodontic
terms.
IAC- Integrated abutment crown.
ICER- Incremental Cost
effectiveness ratio
IS - Implant supported
IT-S –Implant tooth supported.
M-C- Mechano-chemical
OD-Over denture
PFM: Porcelain fused to metal
PBM: Porcelain fused to base metal.
PFG: Porcelain fused to Gold.
Ret-Retention
RPD: Removable partial denture.
S- Single crown
Sp-splinted crown
VAD- Virtually aided design.
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Glossary:
Abutment: The portion of an implant
above the neck used to provide support
for a fixed, fixed-detachable or
removable dental prosthesis.
Abutment screw: that component which
secures the dental implant abutment to
the dental implant body.
Abutment post: that component of a
dental implant abutment which extends
into the internal structure of a dental
implant and is used to provide retention
and/or stability to the dental implant
abutment.
Angled abutment: The prosthetic
coupling component of an implant
designed to fitted with a crown or other
anchorage attachment: available in a
variety of angles upto 35◦.
Antirotation component: a component
of the implant body-hexagonal, tapered
[morse] or with some other internal
design placed to prevent unwanted
abutment rotation.
Cantilever: a beam or bridge segment
which is unsupported at one end.
Cantilever FPD: a fixed bridge which is
unsupported at one end.
Cement: a bonding substance designed
to temporarily or permanently bond
prosthesis to implants or natural teeth.
Ceramics: compounds of a metal and
oxygen formed of chemically and
biochemically stable substances that are
strong, hard bonding, brittle and inert
non- conductors of thermal and electric
energy characterized by ion
Crown: the portion of a tooth protruding
into the mouth for purpose of chewing or
a prosthetic replacement of this structure.
Endosseous implant: a device placed
within alveolar or basal bone designed to
serve as a prosthetic abutment.
Fabrication: the construction of a
structure or prosthesis.
Implant crown: a casting placed over an
implant abutment designed to assume the
role of a natural crown.
Implant loading: placement of
prosthetic devices to bring an implant
into function.
Implant prosthesis: a denture supported
in whole or in part by implants.
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Implant system: a coordinated set of
instruments and supplies designed to
perform the various steps of implant
insertion, prosthetic reconstruction. It
represent a specific concept, inventor or
patent.
Luting agent: any material used to attach
or cement restorations to prepared tooth
or implant abutment.
Metal ceramic: tooth/implant retained
fixed dental prosthesis that uses a metal
substructure upon which a ceramic
veneer is fused.
Porcelain: a ceramic material formed of
infusible elements joined by lower fusing
materials.
Prosthesis: an artificial device used to
substitute for a lost or under functioning
body part.
Prosthesis screw: a screw designed to
fasten a prosthesis to an implant or to
bone.
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ExecutiveSummary:
Background:
Knowing the success/failure rate, survival rate, type and incidence of maintenance
events associated with each retention type and associated costs help the dentist in choosing
appropriate retention system.
Objectives:
To assess the various retention types used for the partially edentulous implant supported
fixed prosthesis in terms of following outcomes: success, failure, survival and cost
effectiveness.
Methods:
Three tier electronic database search [ I. MEDLINE via OVID, EMBASE, PUBMED, II-
Cochrane reviews, CENTRAL, INAHTA, CADTH, CRD, III- clinical trials.org, google
scholar, IADR abstracts, Journal databases] supplemented by manual search was
conducted to identify best, good, fair graded study designs reporting of atlas one year
follow-up. Neither language, nor date of publication restrictions applied. Randomized
clinical trials, controlled clinical trials, prospective studies, and retrospective with follow-
up clinical examination study designs reporting retention methods with relevant clinical
outcomes [Prosthesis success/failure/ technical complications/mechanical
complications/biomechanical complications, implant failure] were included. Selected
studies were critically analyzed using EHPP” Quality assessment tool for quantitative
studies”. Those studies that scored poor in the quality assessment were excluded from data
synthesis. Two reviewers independently carried out the screening of eligible studies. Data
from the studies that scored strong or medium in the quality assessment were used to
estimate 5 yr, 10 yr, 20 yr success, failure and complication results. The data was
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categorized into sub groups based on Prosthesis design, Implant characteristics, Abutment
characteristics and the edentulous site. Chi square test was used to investigate the
heterogeneity. Markov Cost effectiveness model was used to analyze the cost
effectiveness.113 from 3875 [initial search] were selected for quality assessment. Kappa
inter reviewer agreement was 0.957 at stage 1, and 0.857 at stage 2. 15 % of the studies
were rated as strong, 77% as medium and 8% as weak based on the quality assessment tool.
The strong and medium [n=104] studies were selected for data extraction and analysis.
Among 104, 14.42% were RCTs, 4.8% CCTs, 53.84% prospective studies and 26.92%
retrospective.
Key limitations of this report are related to the poor availability of data and the suitability
of available data for statistical pooling. So the research question “Do different retention
systems affect the survival, event free and failure rates of IS- prosthesis” is not fully
answered.
Conclusion:
From the evidence generated from the studies meeting the inclusion criteria, within
limitations, cement retained prosthesis [single crown and FPD] is comparatively better than
screw retained prosthesis in partially edentulous patients.
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1. INTRODUCTION1.1. Context and Issues: 1.1.1. PartialEdentulism
Partial Edentulism can be defined as absence of some but not all of natural teeth1,3.
Dental caries and periodontal disease are the major causes of partial tooth loss. The partially
edentulous patients are diverse in nature with wide variations in physical and health
conditions. Traditionally these patients are categorized into four types based on the site of
missing teeth: Class 1- Bilateral edentulous areas located posterior to remaining natural
teeth, Class 2- unilateral edentulous area located posterior to remaining natural teeth, Class
3- a unilateral edentulous area with natural teeth both anterior and posterior to the missing
area, Class 4- single but bilateral [i.e. crossing the midline] edentulous area located anterior
to the remaining natural teeth3.
1.1.2. Epidemiology
Based on ACP and AAID, 178 million people [about 10% population] in US are
partially edentulous. This number is expected to be around 200 million in the next 15 years.
Approximately 2.3 million implant supported crowns are made annually4,5. Canadian
Health Measure Survey [CHMS 2007-2009] reported that 14.6% of Canadian adults aged
20 to79 years have fewer than 21 teeth6. 21.4% of population aged 15 to 74 years use partial
prosthesis and 71.5% of 65 to 74 years old are partially edentulous.7
1.1.3. ImportanceoftreatingpartialEdentulism
Tooth loss is a permanent irreversible condition. The consequence of tooth loss is
associated with loss of function, speech, loss of self-esteem and deterioration in the quality
of life. Tooth loss in the anterior region results in significant esthetic impact. Managing
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tooth loss in partial edentulism is considered as an essential necessity to improve one’s
form and function.8
1.1.4. Availabletherapeuticoptions
Partial tooth loss is majorly categorized into tooth-supported (those with teeth
both anterior and posterior to the missing teeth) and tooth-tissue supported (teeth either
anterior or posterior to the edentulous space)9. The possible therapeutic options for partial
edentulism are summarized in the following Table-1
Table: 1. Therapeutic options for partial edentulism:
Tooth Supported Tooth-Tissue Supported
- Removable partial denture[RPD] - Fixed partial denture[FPD] - Implant supported prosthesis
- Removable partial denture[RPD] - Implant supported prosthesis
1.1.5. RationaleinchoosingImplantsupportedprosthesis
Among the possible therapeutic options RPDs have the lowest patient acceptance
rate in dentistry. The success rate of the conventional RPD was estimated as 40% at 5 years
and 20% at 10 years10. Mobility of abutment teeth, greater plaque retention, higher
incidence of caries, speech and taste inhibition, non-compliance of use are some of the
disadvantages associated with the RPD11-13. If the adjacent teeth are intact or with minor
restorations, conventional FPD is used.
FPD has been the treatment of choice for replacing missing teeth in partial edentulism for
more than six decades. The mean life span was estimated as 9.6 to 10.3 years14. Creugers
et al [1994] calculated the survival rate for FPD as 74% based on 42 reports with mean
observation period of 15 years15. Libby [1997] in his report mentioned that 15% abutment
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teeth supporting FPD required endodontic therapy, and over 20% of the abutments are at
caries risk16.
Salient conclusions have emerged from anecdotal studies that RPD may be associated with
problems of patient compliance, acceptance and tissue tolerance; while FPD with the
sacrifice of sound tooth structure and risk of pulpal injury. Additionally, economic
comparisons between dental implants and FPDs in partially edentulous cases concluded
that implant supported prostheses would be cost effective in the long term. The detailed
initial cost and maintenance comparisons for 30 years is shown in the table-2. This is based
on the assumption that a young patient receives a FPD which has to be replaced at 10 yr,
20 yr, & 30 yr[ initial cost 2700$+ 3 x 2700$= 10,800 $ total cost] and Implant supported
single crown replacing the crown at 10 yr, 20 yr, 30 yr [ initial cost= 4000$ +3 x 900$=
6700]. Breakeven point reached at 7 years.
Initialcost 10years 20years 30years
Singleimplant
supportedcrown4000 4900 5800 6700
3unitFPD 2000 5400 8100 10800
Table 2: Economic comparison [Cumulative investment] between single implant supported crown and three unit fixed partial denture17.
Furthermore, maximum number of posterior teeth safely replaced with
conventional FPD is ideally two, but three is acceptable. Implants have been an alternative
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to other therapeutic options for more than 30 years. To date, implants indicate comparable
or better success rates compared with FPD/RPD19-22. Based on the facts and its virtue of
restoring missing teeth without damaging adjacent teeth or supporting structures, implant
supported prosthesis may be the ideal choice for treating partially edentulous patients.
1.1.6. Importanceofretentionsysteminimplanttreatment
Almost 15 years after its use in completely edentulous patients, dental implants
were proposed to support prosthesis in partially edentulous conditions17,20 in 1983 by Zarb.
To date, the five year survival rate is estimated to be more than 90% for most of the implant
systems20. Implants have no resilience in the bone and the fit between the implant and the
superstructures is responsible for the development of biomechanical stresses and associated
events23. Among the various parameters that determine the survival of implant supported
prosthesis, the method to retain the prosthesis to the implant or superstructure determine
the nature and complexity of maintenance events it undergoes over its life span. Thus, the
type of connection [retention system] between the prosthesis and implant influences the
complication rate and longevity of the replacement24-29.
1.2. Retentionsystem options.
Three types of retention systems were reported in the literature for the partial
edentulism: 1. The prosthesis screwed onto the implant directly 2. The prosthesis screwed
to abutment 3. The prosthesis cemented to abutment. The first and second methods are
termed as screw retained implant supported prosthesis and the third one is called as cement
retained prosthesis. However, for this report we would like to consider the retention systems
as follows 1. Screw retained 2. Cement retained and 3. Mechano-chemically retained. The
third category is based on the availability of screwless, cementless system to
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attach the prosthesis to implants30. The category (the prosthesis screwed onto implant
directly) in the traditional classification is included in the mechano-chemical retention
system. This is because the crown is chemically bonded (porcelain fired on the metal coping)
over a metal substructure which later screwed to the implant. This is similar to screwed
abutment.
1.3. Issues:
Today a dentist has a difficult task of choosing implant systems and its components.
Dental Implants are translated from the phase of development [1990s] to phase of
predictable implants in 2000, now we are in phase of confusion as a result of numerous
implant systems and a variety of associated components. The numbers of available implant
systems grown from 98 in 2000 to 600 in 2008 from atleast 146 different manufacturers20,
31. Moreover, it is further complicated with 1500 different abutments varied by material,
shape, size, diameter, length, and surface and interface geometry. Virtually all major
manufacturers documented success rates more than 90%20, 32. Although long-term
predictability is well documented, the major issue is the long-term stability of abutment and
prosthesis31.This is primarily determined by the retention system used to attach the
prosthesis to the implants. Choosing an appropriate dental implant system from hundreds
of implant systems and thousands of different available components, is simplified by
choosing the type of retention system. Nevertheless, available evidence in choosing
retention system is impeded by the paucity of literature or extrapolation of results from
completely edentulous conditions.
• About 36 reviews, 7 meta-analysis and 2 consensus statements reported, either
directly or indirectly the outcomes of implant supported prosthesis in partially
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edentulous patients. The available systematic reviews and meta-analysis have been
mainly focused on implant survivals and technical complications with little evidence
between the incidence and retention systems. Moreover, the observations and results
are mixed with data from both partially edentulous and completely edentulous
patients. Very little information is available comparing the different retention
systems used in partial edentulism.
• Partially edentulous patients differ substantially from completely edentulous
patients by anatomy, biomechanics [bite force, tooth wear, occlusal scheme] and
microbiology. Hence, extrapolating results from completely edentulous or mixed
with completely edentulous cannot be justified.
• Lack of evidences in costs associated in maintaining the prosthesis.
2. OBJECTIVES
The aim of this health technology report is to systematically review the literatures
to assess the outcome of different retention systems used in partially edentulous patients to
support the implant prosthesis and to determine the type of retention systems that can be
recommended for clinical application. Thus, the objectives are to assess the effects of
different retention systems (screw retained, cement retained, mechano-chemically
retained) used for Endosseous implant supported prosthesis in partially edentulous patients
in the terms of following outcomes:
§ Failure.
§ Survival
§ Event free
§ Cost effectiveness
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Failure is defined as implant which is not in service or not able to support the prosthesis.
i.e. implant is completely lost/ fractured.
Survival is defined as implant that is in service, but the prosthesis may or may not be. If
the prosthesis and implant components remains insitu but require minor corrections in
order to continue its function, it is termed as minor complication events. If the prosthesis
or implant components need major modifications to continue its function, it is termed as
major complication events. The comprehensive list of minor and major complications
events are enumerated in the table: 3
Table: 3 List of survival events
Minor Complication events Major complication events
• Abutment screw loosening • Prosthesis screw loosening • Decementation, fracture of luting
cements. • Porcelain fracture/ Ceramic chip
that did not necessitate replacement of prosthesis.
• Loss of screw access hole. • Total loss of retention. • Biological events that does not
require change of prosthesis/ implant components [ just require oral prophylaxis]
• Abutment screw fracture • Prosthesis screw fracture • Abutment fracture • Porcelain fracture/ Ceramic chip
that necessitate replacement of prosthesis.
• Biological events that require change of prosthesis/ implant components
• Crown remake • Crown lost
Event free is defined as prosthesis being free of all complications and symptom-free over
the entire observation period. The report seeks to answer the following focused research
question: Do the different retention methods affect the success, failure, survival and cost
of Endosseous supported prostheses for partially edentulous patients aged 15 to 90 years?
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3. METHODS3.1. Systematic review
3.1.1.Literaturesearchstrategy.
Published literature was identified by searching Ovid interface: MEDLINE
in process & other non-indexed citations, EMBASE and PUBMED. The search was
not restricted to the year of publication and the search date was until Jan 30th 2015.
Regular alerts were established to update the search until April 7th 2015. Both
National library of medicine MeSH and keywords were used. The comprehensive
literature search strategy is shown in table-4. Health technology databases [INHATA,
CRD, Cochrane registry and CADTH] were searched for existing health technology
reports. CENTRAL and clinicaltrials.gov were searched for the clinical trials. Google
scholar and IADR abstracts were searched to identify grey literatures. The literature
search was further complimented by searching the major journal database( Wiley, Elsevier,
Quintessence, Sage pub) that publishes dental implant studies and the bibliographies
of systematic reviews, meta-analysis and consensus statements.
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Table-4: Literature search strategy
Focused Question: Does different retention methods affect the success, failure, survival and cost of Endosseous supported prostheses for partially edentulous patients aged
15 to 90 years?
Population Partially edentulous patients aged 15 to 90 years.
#1 ((((((edentulous*) AND partial*)) OR ((dentulous*) AND partial*)) OR ((partial) AND ((dental arch) OR dental arch*))) OR (((partial edentulism) OR partial edentulous*) OR jaw, edentulous, partially))))
Intervention Endosseous implant supported prostheses
#2 (((((((((dental implants, single tooth) OR ((((((dental*) AND implant*) AND endosseous*)) OR ((dental*) AND implant*)) OR (((dental implants) OR dental implant*) OR dental implantation, endosseous))))
Comparison Screw retained/Cement retained/Screwless, cementless/mechano- chemical
# 3(((((((dental) OR dental*)) AND ((bridge) OR bridge*))) OR ((((dental) OR dental*)) AND ((crown) OR crown*))) OR ((((denture, partial, fixed) OR dental prosthesis retention)) OR (((((dental prosthesis) AND implant) AND supported)) OR ((((((((((((((((((dental prosthesis, implant supported) OR implant supported prosthesis*) OR implant supported prostheses) OR dental implant-abutment design) OR implant crown*) OR implant bridge*) OR suprastruct*) OR implant suprastruct*) OR fixed partial denture) OR fixed partial denture*) OR fixed denture partial) OR fixed denture partial*) OR FPD) OR FDP) OR (crown and bridge)) OR (crown* AND and bridge*)) OR crowns) OR bridges)))))) AND ((((((((screw) AND fixation)) OR screw fixation)) OR ((screw retain) OR ((((dental*) AND screw*)) OR ((((((screw*) AND retention*)) OR ((screw retained) OR screw-retained))) OR ((screw retained crown*) OR screw retained crown)))))) OR ((chemomechanically bonded) OR ((dental cement*) OR ((((cement) AND retention)) OR ((((cement) AND retained)) OR (((((((((((cementation) OR cement retain) OR cement retained) OR cement retention) OR cement fixation) OR screwless) OR integrated abutment crown) OR integrated abutment crowns) OR locking-taper implant) OR locking-taper implant*) OR dental cements)))))))
Outcome success, Failure, survival and cost
#4 (((economic analysis) OR (((cost benefit analysis) OR cost-benefit analysis) OR cost effectiveness))) OR (((((patient safety) OR safety)) OR ((((((((((((((screw) OR cement) OR ceramic*) OR porcelain*) OR crown*) OR denture, partial, fixed) OR bridge*)) OR abutment)) AND ((fracture) OR deformation))) OR (((dental leakage) OR screw loosening) OR abutment loosening)) OR (((((((((((((((survival) OR survival analysis) OR survival rate) OR success) OR success rate) OR longevity) OR failure) OR prosthesis failure) OR crown failure) OR bridge failure) OR abutment failure) OR treatment outcome) OR loss of retention)) OR ((((((((((((technical*) OR biological*) OR prosthetic*) OR prosthodontic*) OR restorative*) OR esthetics*)) AND ((complication) OR complicat*))) AND failure*)) OR ((((((((technical*) OR biological*) OR prosthetic*) OR prosthodontic*) OR restorative*) OR esthetics*)) AND ((complication) OR complicat*))))))))
Databases 1. Ovid MEDLINE, EMBASE, PUBMED. 2. Cochrane registry, CENTRAL, INAHTA, CADTH, CRD 3. clinicaltrials.gov, Google scholar, Journal database [Wiley, Elsevier, Quintessence, Sagepub]
Search Strategy Database 1: #1 Database 2&3 : “oral implants”, “dental implants”, “ partially edentulous jaw”, “implant supported prostheses”, “ fixed partial denture”, “crown and bridge”, “single crowns”, “Endosseous dental implants”.
Filters None Journals searched through the journal database
Implant dentistry, IJOMI, Clinical oral implants & research, JDR, JPD, IJP, JOP, JOR, JOI.
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3.1.2. Selection criteria and methods.
Three sets of sequential inclusion and exclusion criteria were used at title, abstract
and full text review process. The detailed inclusion and exclusion criteria are tabulated in
the table-5. Language restriction was not applied at the initial stage. Study observation
periods less than one year and less than ten patients were excluded. Systematic reviews,
meta-analysis and consensus statements were excluded after full text review. Retrospective
studies without clinical follow up examinations were excluded. This was done to avoid
potential or possible inaccuracies in description that are purely based on patient self-reports
or chart reviews. In the case of multiple reports of same cohort at different time periods,
reports with longer observation time was included.
Two reviewers [MR, AN] carried out the review process [Title screening, abstract
screening, full text evaluation] independently to identify the potentially relevant articles to
be included in this report, based on the inclusion and exclusion criteria. Selected full text
articles were retrieved and assessed independently for possible inclusion. Disagreements
between the reviewers were discussed until consensus was reached. Kappa inter author
agreement was carried out at the abstract screening, full text selection to validate the inter
author agreement.
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Table-5: Inclusion and Exclusion Criteria Inclusion Exclusion
Title Review
Human subjects. Endosseous Implant supported single crowns, FPDs RCTs, Controlled clinical trials, Retrospective, Prospective studies, Case reports, case series, Systematic reviews, Meta-analysis. Cement retained, screw-retained, integrated abutment crowns, mechano-chemical retained prosthesis
Invitro studies. Animal studies. Expert opinion, letter to editor, narrative reviews, overviews Over dentures. Completely edentulous
Abstract Screening
Human subjects. RCTs, Controlled clinical trials, Retrospective, Prospective studies. Systematic reviews, Meta-analysis
Studies less than 10 patients. Studies based on questionnaire or interviews. Studies which doesn’t report atleast one outcome measure as defined earlier. Case reports, Case series. Combination prosthesis.
Full text evaluation
Human subjects. RCTs, Controlled clinical trials, Prospective studies, retrospective studies with clinical follow up examination Studies reported details of supra structure characteristics. English & Indexed publications.
Non-English. No characteristics of implants, supported prosthesis. Observation period less than 1 year after loading. Multiple studies of same trial /study Retrospective studies without clinical follow up. Systematic reviews, Meta-analysis. Studies from which data on outcome variable are not directly retrievable or not able to be calculated. Studies considering only biologic complications [peri-implantitis, marginal bone loss, radiolucency, bleeding index, suppuration, recession, fistula/sinus, soft tissue lesions] without considering technical or prosthodontic or mechanical complications. No clinical outcome reviewed at the follow up visit
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14
3.1.3. Data extraction strategy.
A priori (pre-drafted) extraction table covering the patient characteristics, implant
and prosthesis characteristics, type of retention, study characteristics and the outcome of
study were used to extract the data from the selected full text studies (Annexure 1,2).
Information on the following outcomes, failure of implants after prosthesis placement,
failure of prosthesis, minor technical complications, major technical complications,
biological complications, event free prosthesis were extracted from the selected studies.
3.1.4. Critical Appraisal of included studies.
The authors selected effective public health practice project quality assessment tool
(Annexure 3) to critically appraise the selected studies. The tool rated the quality of article
as strong, moderate or weak based on six domains: selection bias, study design,
confounders, blinding, data collection, withdrawals and dropout33, 34. Those studies, which
scored weak, were excluded from the final analysis.
3.1.5. Data analysis and Meta –analysis methods.
Information on failure of implants after loading, abutment screw loosening,
prosthesis screw loosening, crown loosening, re-cementation, abutment screw fracture,
abutment fracture, prosthesis screw fracture, minor porcelain chip, major porcelain/ceramic
veneer fracture, loss of retention, implant fracture, minor biological events and major
biological events were abstracted from the publications directly. From this information,
failure event rate, survival rate based on complication events and event free rate [1- failure
events + complication events] were calculated by dividing the total
15
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
number of events by total prosthesis exposure time. The total prosthesis exposure time is
sum of
1. Exposure time of prosthesis that was followed for the whole observation period.
2. Exposure time of prosthesis until implant is failed.
3. Exposure time of prosthesis until it is dropout from the observation for those
patients that did not complete the observation period due to change of address,
death of the patient and missed appointments.
If this information was not available for all these three parameters, multiplying total
number of prosthesis and the mean observation period derived the total exposure time.
The number of events or event free was considered to be a Poisson distribution. Poisson
regression would be an appropriate option for rate data where the rate is a count of events
occurring to a unit of observation. When analyzing pooled data from several clinical studies,
the estimated event rate/100 reconstructions/year is a useful parameter for statistical
comparison of the risk for complication or failure at 3,5,10 years. Based on the hypothesis
when the event rate �is constant over time, the proportion of the event free population
decreases exponentially over time. This proportion is exactly the same as the survivor
function s(t) = e-�t where �is the event rate and t is time of observation. Using this 5year,
10 year, 15 year, 20 year and 25 year cumulative survival proportion, failure proportion,
and event free proportion were calculated for the each studies with 95% confidence interval.
The detailed formula and data used for calculating each proportion is shown in the
annexure 4.
Anticipating reasonable heterogeneity among the selected studies [study population,
sample size, study setting, objectives] random effect model was used to obtain the summary
16
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
estimate of the proportions. Goodness of fit statistics was used to reassure the heterogeneity
of study specific event rate and associated P value was calculated. P value <0.05 indicates
heterogeneity, further I2 statistics were also reported along with the P value. Where there is
no statistical heterogeneity observed, both models were used to calculate the proportion
rate and forest plot was generated. Subgroup analysis [by prosthesis design, abutment
material type, prosthesis material type, implant-abutment connection type, edentulous site,
abutment-implant attachment mechanism, luting type] was performed using Meta
regression to identify the outcome differences. All P values were two sided.
All statistical and meta-analysis calculations were carried out using commercially available
software comprehensive meta-analysis [CMA, Biostat, Englewood, NJ,USA] and Stata
version 13.1[ Stata corp LP, college station Tx,USA].
3.2. Economic analysis. 3.2.1. Type of economic evaluation.
The evaluation was a cost effective analysis with the incremental cost effectiveness
as the primary outcome measure.
17
3.2.2. Model structure.
Cost effectiveness was determined as the ratio between survival probabilities of
each treatment modality divided by total fee for that treatment. A Markov model was built
to stimulate the lifetime of an implant supported prosthesis in partially edentulous patients.
A decision tree over a 15 year period was developed to estimate event free rate which was
defined as reconstructions and implants are free from any symptoms and complication
events. The model estimates the lifetime cost and longevity for each type of retention
system.
Fig1. Markov transition Model
18
Fig:2: Decision Tree
3.2.3. Data inputs.
All outcome data was based on the results of our meta-analysis. We assume, this
2011-2012 ADA survey35 was used to calculate the associated clinical cost[Annexure-5].
The lab cost associated with each prosthesis was obtained from the various commercial
laboratory websites and averaged. The overhead costs [labor costs] were obtained from the
US labor statistics36 [Annexure-6]. Associated patient time and dentist productivity time
were not included in this analysis.. Markov transition model was constructed first with
parameters and then it is transformed into decision tree. At the starting point our strategy
model was event free. Cost effective ratio was calculated to determine the treatment
modalities rank.
3.2.4. Costs.
19
The costs incorporated within the model included those initial costs of placing
implants, abutments and crowns and direct cost associated with minor /major
adjustments/remakes. This analysis was conducted from the perspective of North America
with costs adjusted to 2015[4.3% cumulative rate of inflation]37.
3.2.5. Assumptions. The following assumptions were made in this economic evaluation:
- Initial cost for screw retained and cement retained are same assuming that
implant does not need any adjuvants or grafts.
- All costs were obtained from ADA 2011-12 survey and the charges of a
general dentist were used, Further the 2011-2012 price list in US dollars were
adjusted to 2015 April 15th [ 4.3% inflation rate].
- Only direct cost involved in replacement is considered [overhead cost, loss
of time by operators & patient other indirect costs are not considered because
of lack of information on public domain and heterogeneity in methods,
materials and average per hour earnings.
- FPD is considered as 3 unit supported with two free standing implants.
- If the implant is failed after loading, we assume patient is not going for a new
implant.
- Minor complication events are prosthetic screw tightening and/ abutment
screw tightening, and occlusal material replacement/porcelain chip
adjustment for screw retained prosthesis and recementation & adjustment for
cement retained prosthesis.
- Major complication event means: screw – maintenance [screw replacement
and abutment replacement], Cement- sectioning of old prosthesis, abutment
20
replacement and crown remake. Assuming cement-retained prosthesis has
limited retrievability option and screw retained has more abutment
replacement rather than crown remakes.
4. RESULTS 4.1. Selection of primary studies
The literature search identified 896 citations. Upon screening the titles and
abstracts, 329 potential relevant publications were retrieved for further scrutinizing.
Among the 329, 216 citations were excluded. Thus 113 studies were selected for inclusion
into qualitative and quantitative analysis. Of those 113, nine studies were excluded from
final inclusion based on the quality score/( weak). Total 104 studies were included in the
meta analysis. To be considered for inclusion, a study needed to have atleast one outcome
of interest. The study selection process is shown in PRISMA flow chart in table-6. Table-
7 summarizes the basic characteristics of the included studies. Table -8, 9 briefs the
analysis of excluded and included studies.
21
Table 6: PRISMA Flow diagram
Recordsidentifiedthroughdatabasesearching
(n=2518)
Additionalrecordsidentifiedthroughothersources
(n=1357)
Recordsafterduplicatesremoved(n=896)
Recordsscreened(n=896)
Recordsexcluded(n=567)
Full-textarticlesassessedforeligibility(n=329)
Full-textarticlesexcluded,withreasons(n=216)
Studiesincludedinquantitativesynthesis
(meta-analysis)(n=104)
Studiesincludedinqualitativesynthesis
(n=113)
Eligibility
22
Table-7:BasicCharacteristicstableNo Reference Retention
type Study design
No of Patients M F T
Age range
No of Implants
No of prosthesis
Prosthesis design
Observation period
Drop outs
Study setting
1 Akca, 2008 Cement Prospective 13 16 29 31-73 64 49 FPD 24m-30m 0 University 2 Andersen,
2001 Cement Prospective 33 24 57 31-33 65 65 S 5 Yr 8/57 University
3 Andersson, 2003
Screw, cement
Prospective 26 29 55 17-54 60 60 S 3 Yr 5/60 University
4 Andersson, 1998
Screw, cement
RCT 14 18 32 15-71 103 36 FPD 5 Yr 6/36 Multi
5 Aparicio, 2001
Screw Retrospective 10 15 25 49-59 101 29 FPD 21-87 m 5/32 University
6 Avivi-Arber, 1996
Cement Prospective 22 19 41 14.5-63.9
49 49 S 1.8 Yr University
7 Balleri, 2010 Screw Prospective 6 14 20 38-63 40 20 FPD 1 Yr 0 University 8 Balshi 1996 Screw Prospective 15 29 46 30-70 71 73 S,SP 3 Yrs 0 University 9 Bambini,
2001 Screw Retrospective 35 24 59 38-65 40 20 FPD 1 Yr 0 NR
10 Becker, 2004 Screw, cement
Retrospective 17 18 35 33-75 115 60 C 10 Yrs - NR
11 Becker, 1995 Screw Retrospective 6 16 22 48-73 24 24 S 24m 2/24 Specialist clinic 12 Behneke,
2000 Screw- cement
Prospective 27 28 55 17-81 114 68 S,FPD 5 Yr 15/114 University
13 Bergenblock, 2012
Cemented Prospective 22 25 57 15-57 65 65 S 17-19 Yr 13/65, 10/57
Specialist clinic
14 Bischof, 2006 Screw, cement
Prospective 91 121
212
22-88 249 237 S, FPD 2 Yr Private
15 Bonde 2010 Cemented Retrospective 29 22 51 - 55 55 S 7.5-12 Yr 3 University 16 Bragger 2005 Screw-
cement Prospective 34 55 89 26-88 102 69
22 S
FPD 8-12 Yrs - University
17 Brown, 2011 Screw CCT 9 18 27 21-71 28 28 S 1 Yr 2/28 University 18 Cabello, 2013 Screw-
cement Prospective 7 7 14 34-71 14 14 S 1 Yr 0 Private
19 Camargos Gde, 2012
Screw- cement
Retrospective 12 32 44 24-72 71 71 S 2-13 Yr 3 University
20 Cannizzaro, 2008
Cemented RCT 19 21 40 18-64 108 108 S 3 Yr 0 Private
21 Cannizzaro, 2013
Cemented RCT 19 21 40 21-72 82 32 SP 5 Yr 1 Private
23
No Reference Retention type
Study design
No of Patients Age range
No of Implants
No of prosthesis
Prosthesis design
Observation period
Dropouts Study setting M F T
22 Cannullo 2013
Cemented RCT 11 6 20 29-81 20 20 S 2 Yr 0 Multicenter
23 Cha, 2013 Screw, cement
Retrospective 57 63 120 18.8-81.1
136 136 S 5 Yr 0 Nr
24 Cho, 2004 Screw Prospective 50 56 106 20-74 213 107 S, FPD 3-7 Yr 0 University 25 Cooper,
2007 Cemented RCT 21 26 47 30.6(A) 53 53 S 3 Yr 11/53 University
26 Cordioli, 1994
Screw Prospective 17 30 47 15-67 67 67 S 5-6 Yr 4/47 -
27 De Boever, 2006
Screw, cement
Prospective 48 57 105 25-86 283 80 92
S FPD
40m - University
28 Drago, 2003 Cement Prospective 22 51 73 17-72 110 110 S 1Yr - - 29 Engquist,
1995 Cemented Retrospective 32 26 58 26(A) 82 82 S 1,2,5 Yr - University
30 Esposito, 2014
Cemented RCT 7 8 15 28-68 38 38 S 3 Yr 0 Multicenter
31 Glauser, 2004
Cemented Prospective 11 16 27 26-75 54 54 S 1-4 Yr - -
32 Gotfredsen, 2012
Cemented Prospective 10 10 20 18-59 20 20 S 10 Yr 1 University
33 Grandi, 2012
Cemented RCT 11 17 28 39-64 56 28 SP 1 Yr 0 Multicenter
34 Gulje, 2013 Screw RCT 48 47 95 26-70 208 95 SP 1 Yr 2 Multicenter 35 Gunne, 1994 Screw Prospective 42% 58% 159 18-70 521 197 FPD 3 Yr 5 Multicenter 36 Haas 2002 Screw Prospective 35 36 71 10-69 76 76 S 5 Yr 2 University 37 Halg, 2008 Cemented Prospective 21 33 54 24-83 78 54 FPD 5.3 Yr - Private 38 Hartlev,
2013 Cemented Retrospective 34 21 65 17-82 55 55 S 33m - Private
39 Henry 1995 Cemented Prospective 29 14 43 16-70 53 51 S 1 Yr 2 - 40 Henry 1996 Screw Prospective - - 92 - 106 106 S 5 Yr 18 Multicenter
41 Hosny, 2000 Screw Prospective 6 12 18 37-65 78 18 FPD 14 Yr 0 University
42
Hosseini, 2013
Cemented Prospective 24 35 59 18-50 98 98 S 3 Yr 0 University
43 Jacobs, 2010 Screw Split 6 12 18 32-63 95 - FPD 16 Yr 6/18 University
44 Jemt, 2009 Screw, cement
Retrospective 25 10 35 18-75 41 41 S 10 Yr 11/35 University
24
No Reference Retention type
Study design No of Patients Age range
No of Implants
No of prosthesis
Prosthesis design
Observation period
Dropouts Study setting M F T
45 Jemt, 2003 Screw Prospective 15 27 42 25-74 170 63 FPD 5 Yr 7 University 46 Jemt, 1993 Screw Prospective 36 31 67 22-78 259 94 FPD 5 Yr 7/67 University 47 Jemt, 1992 Screw Prospective 42 45 97 16-77 354 127 FPD 1 Yr 14/97 University 48 Karlsson,
1997 Cemented Prospective 26 21 47 16-69 47 47 S 2 Yr 4/47 Multicenter
49 Khraisat, 2008
Cemented Retrospective 23 26 49 17-85 87 87 S 1-6 Yr - Multicenter
50 Kourtis, 2004
Screw, cement
Prospective 171 234 405 18-83 1692 1111 S,FPD, SC, CL
1-12 Yr - Private
51 Kreissl, 2007 Screw Prospective 29 47 76 18-76 205 112 SC,C,FPD 5 Yr 0 - 52 Krennmair,
2002 Screw, cement
Retrospective 45 67 112 16.5-56.8
146 146 S 7 Yr - -
53 Krennmair, 2010
Cemented Retrospective 82 134 216 45.2-63.4
295 180 S,FPD 3 Yr - Private
54 Krennmair, 2011
Cemented Retrospective 11 27 38 38-62 76 36 FPD 3 Yr 2/38 -
55 Larsson, 2010
Cemented CCT 6 12 18 37-70 - 25 FPD 5 Yr - University
56 Lee, 2011 Cemented Prospective 68 93 161 20-79 207 207 S 3 Yr - University 57 Lekholm,
2006 Screw Retrospective 9 7 16 43-87 112 24 S,FPD 10Yr 37% Public service
58 Lekholm 1999
Screw Prospective 54 73 127 18-70 461 197 FPD 10Yr 40 Public service
59 Levine, 2007 Cemented Retrospective 182 228 410 18-78 499 499 S 54m - Multi clinic 60 Lindh, 2001 Screw Prospective 182 228 410 18-78 95 95 S 2 Yr 6 University 61 Linkevicius,
2009 Cement CCT 11 8 19 23-71 46 46 FPD 1yR 3 Private
62 Malo, 2000 Screw, cement
Retrospective 18 31 49 14-70 94 23 31
FPD S
4 Yr - Private
63 Mangano, 2001
Cemented Retrospective 33 36 69 16-61 80 80 S 3.5 Yr - -
64 Mericske-Stern, 2001
Screw, cement
Prospective 24 48 72 19-82 109 109 S 1-9 Yr 3 -
65 Mertens, 2011
Screw- cement
Prospective 5 12 17 40-83 49 31 4
S FPD
5 Yr 2 University
66 Montero, 2012
Screw, cement
Prospective 44 27 71 34.6-59.2
93 93 S 26.2m - University
25
No Reference Retention
type Study design No of Patients Age
range No of
Implants No of
prosthesis Prosthesis
design Observation
period Drop outs
Study setting M F T
67 Muftu, 1998 Cemented Prospective 84 84 168 - 432 432 S 4 Yr 2 - 68 Naert, 1992 Screw Retrospective 52 94 146 21-83 509 217 FPD 77m - University 69 Nedir, 2006 Screw
Cement Prospective 91 145 236 18-89 465 171
93 S
FPD 8 Yr 0 Private
70 Nissan, 2011 Screw, cement
Prospective 16 22 38 38-70 221 76 FPD 18-180m 0 Private
71 Ormianer, 2006
Cemented Prospective 9 9 18 18-62 22 22 S 30m - Private practice
72 Ortorp, 2008 Screw CCT 39 65 104 27-78 351 120 FPD 10 Yr 35/104 - 73 Palmer, 2005 Cemented Prospective 10 11 21 27-65 21 - FPD,C 3 Yr - - 74 Palmer, 2012 Mechano
chemical Prospective 7 22 29 18-70 28 28 S 3 Yr 1 Hospital
75 Palmer, 2000 Cemented Prospective 5 10 15 16-48 15 15 S 5 Yr - Hospital 76 Pieri, 2011 Cemented RCT 14 24 38 >18
YRS 40 40 S 1 Yr 2 University
77 Pistilli, 2013 Cemented RCT - - 40 - 171 - FPD 1 Yr 2 Private 78 Polizzi, 1999 Cemented Prospective 8 13 21 13-58 30 30 S 3 Yr - - 79 Pozzi, 2014 Cemented RCT - - 34 39-59 88 88 S 1 Yr 0 Multicenter 80 Pozzi, 2012 Cemented Prospective 15 12 27 38-77 81 37 FPD 3 Yr - -
81 Priest, 1999 Cement Prospective 41 58 99 15-76 112 112 S 10Yr 0
82 Romanos, 2000
Cemented Retrospective 29 22 51 34.5-55.7
58 58 S 1.71 Yr 0 -
83 Romeo 2006 Screw, cement
Prospective 61 68 129 52(A) 265 95 S FPD
6.4 Yr 0 -
84 Santing, 2013 Screw, cement
Prospective 29 31 60 >18 Yr
60 60 S 18m 0 University
85 Scheller, 1998 Cemented Prospective 47 35 82 14-73 99 97 S 5 Yr - Multicenter
86 Schmit 1993 Screw Prospective 17 15 32 16.1-63.2
40 40 S 2.9 Yr 0 -
87 Scholander, 1999
Cemented Retrospective 96 87 183 16-71 259 258 S 1-9 Yr University
88 Schropp, 2008 Screw, cement
Prospective 21 24 45 20-74 42 42
Cl 5 Yr - -
89 Schwartz-Arad, 1999
Cemented Retrospective 28 27 55 20-68 78 78 S 5Yr - University
26
No Reference Retention
type Study design
No of Patients Age range
No of Implants
No of prosthesis
Prosthesis design
Observation period
Dropouts
Study setting M F T
90 Schwarz, 2012
Cemented Retrospective - - 241 57.3(A) 533 350 S,FPD 6.9Yr - University
91 Singer, 1996 Cemented Prospective 29 41 70 19-71 225 92 FPD 3Yr - Hospital 92 Sorrentino,
2012 Cemented Retrospectiv
e 39 73 112 18-69 81 81 S 6Yr University
93 Thomsson, 2008
Screw, cement
Retrospective
47 36 83 - 310 89 FPD FPD 1Yr - -
94 Turkyilmaz, 2006
Cemented Prospective 11 8 19 39(A) 36 36 S 3Yr - -
95 Urdaneta, 2008
IAC (Mechano-chemical)
Retrospective
25 34 59 57.2(A) 326 326 S 1.5 Yr 21 -
96 Vanlioglu 2013
Cemented Retrospective
46 49 95 41.2(A) 231 177 S,Sp,FPD 5-10Yr - -
97 Vigolo, 2012 Screw- cement
RCT 8 10 18 27-42 36 36 S 10Yr 2 Private
98 Visser, 2011 Cemented RCT 44 49 93 18-63 92 92 S 5Yr 1 99 Wannfors,
1999 Screw- cement
Prospective 39 30 69 17-72 80 80 S 5Yr 4 University
100 Watson, 1999
Screw- cement
Prospective 16 10 26 22-63 33 33 S 3-4Yr 5 University
101 Wennstrom, 2005
Cemented Retrospective
23 17 40 20-71 44 39 S 5Yr 11 University
102 Yaltirik, 2011
Cemented Retrospective
- - 28 18-65 48 48 S,FPD 5Yr - University
103 Zembic, 2013
Screw Cement
RCT 8 14 22 41.3(A) 40 40 S 5Yr - -
104 Zembic, 2012
Cement RCT 21 26 47 17-76 57 57 S 1Yr 3 Multicenter
28
Table-8:Analysisofexcludedarticles
Reasonforexclusion NumberofarticlesNon-English 3Non-Indexed 2
Multiplereports 8ResultsmixedwithCompletely
edentulousreconstructions
17
Unabletoextractnecessarydata 29Noinformationonretentionsystem 91Lessthanoneyearobservation 1
Systematicreviews,Meta-analysis,Consensusreports
44
Chartreview/patientinterview/retrospectivewithnoclinicalfollowup
21
Table-9:AnalysisofIncludedstudies
Cementretained Screwretained Mechano-chemicalretainedTotalNoof
Prosthesis6178 3029 361
TotalObservationperiod[yr]
29228.64 15412.66 2039.14
TotalNoofsinglecrown
4711 1005 333
TotalNoofSplintedcrown
345 398 28
TotalNoofcantlileverFPD
173 120 -
TotalNoofFPD 949 1506 -NoofRCTstudydesign
12 4 0
NoofCCTstudydesign
7 3 1
NoofProspectivestudydesign
39 28 1
NoofRetrospectivestudydesign
23 16 1
Studiesbasedonqualityscore:Strong-19Medium-85Weak-9
StudiesbasedonyearofpublicationBefore2000-28,2001-2010-43,2011-2015–32
29
RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
4.2. Study Characteristics:
The studies were published over a 23 year period between 1992 and 2015. The
studies reported on three retention system [screw, cement and mechano-chemical] and four
prosthesis design [Single crown, Splinted crown, Cantilever FPD, FPD]. One RCT and 25
observational studies compared atleast two retention systems. The 104 included studies
reported on over 5317 patients between the age of 15 and 90 with 9568 implant supported
reconstructions to manage partial edentulism[ 6049;single crowns, 771; splinted crowns,
293 ; cantilever FPD,2455; FPDs]. Most of the studies [n=44] were done in university
setting. 18 studies reported about the abutment material, 23 studies reported on prosthesis
material, 19 on implant characteristics, and 21 studies reported about the location of
prosthesis [maxilla/ mandible]. The type of luting agent used for cement retained prosthesis
was reported in 17 studies.
4.3. Critical appraisal of included studies and interauthor agreement.
Nine of the 113 included studies scored weak in two or more than one domains and
19 studies didn’t score weak in any of the domains. Among the domains, the most weak
score was for the study design. The detailed scores achieved by each included study was
reported in annexure-8. Kappa inter author agreement was rated very good at the all three
stages. [Title and abstract screening- 0.957, full text evaluation- 0.857, full text screening -
quality scoring of full text-0.952]. The detailed calculations were shown in the annexure-7.
4.4. Data synthesis.
A total of 9568 reconstructions were analyzed with a total exposure time of 46,553.18 years.
Of these 6049 [63.3%] were single crowns, 771 splinted crowns[8%], 293 cantilever
FPD[3%], 2455 FPD[25.7%]. The failure rate , survival rate and event free rate for the three
Dent-655HealthTechnologyAssessment.FacultyofDentistry.McGillUniversity,Canada.
30RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
retention systems and weighing of each study are shown in the figures-1[meta-analysis,
forest plot]. A total of 65 studies reported on cemented, 26 on screw retained and 2 on
mechano-chemical retained single crowns. The failure rate of cemented IS-S
(1.3%[0.97;1.7]), screw IS-S (1.8[1.1;3.1]), and mechano-chemical I-S-S
(1.4[0.9;2.1]).[Table-10]. There were no statistical difference between the different retention
systems and failure outcome.[Table-13]. Table-11 and Table 12 shows the survival rate of
different retention system and sub group variables. Statistically significant differences of
survival rate were demonstrated between the following groups. Screw[8.2%], mechano-
chemical[7.8%] I-S Vs Cement[4.2%], cement splinted crowns Vs screw splinted crowns,
Cement FPD and Screw FPD, Anterior cement retained IS- prosthesis and anterior screw
retained IS-prosthesis. There were no statistical difference between abutment material,
prosthesis material, cement type and implant characteristics [external vs internal hex].
[Table -14]. The relation between survival and complication types in single crowns and FPD
was tabulated in the table-15. The cement retained single crown was statistically different
from screw retained in minor complication events. However, there were no differences seen
with other variables. The annexure -8 shows the meta regression of sub group analysis.
Dent-655HealthTechnologyAssessment.FacultyofDentistry.McGillUniversity,Canada.
31
Table-10: Failure :
Retention & Type
No of studie s
No of prosthesi s
Total exposur e
Annual /100 yr
5 yr 10 yr 15 yr 20 yr 25 yr
Cement -S
65 4719 19814.6 3
1.3[0.97;1.7 ]
2.5[1.8;3.4]
3.5[2.5;5] 4.4[3.1;6.2]
5.1[3.5;7.2] 5.7[3.9;8]
Screw-S 26 1005 7322.68
1.8[1.1;3.1]
3.5[2;6] 3.7[2.2;6.1]
3.8[2;6.8] 4[2.1;7.4] 4.2[2.2;8]
MC-S 2 333 1955.14
1.4[0.9;2.1]
1.59[1.2;2.2 ]
3.1[1.7;5.6]
4.5[2.8;7.4]
6.1[4;9.2] 7.5[5.1;10.8]
Cement - FPD
19 949 4206.4 1.4[0.8;2.5]
4.2[2.7;6.7]
6.8[4.2;10.7 ]
8.6[5.2;13.8 ]
10.2[6.1;16.5 ]
11.6[6.9;18.9 ]
Screw- FPD
22 1506 8700.43
1.5[0.8;2.6]
3[1.8;4.9] 3.5[1.9;6.2]
3.9[2.1;7.2]
4.3[2.2;8] 4.7[2.2;8.7]
Cement- splinted
5 345 1502.6 1.3[0.3;5.6]
2.1[.3;12.9]
2.4[.30;18.8 ]
2.6[.22;23.8 ]
2.74[.2;28.26 ]
2.9[0.2;32.4]
Screw- splinted
6 398 1399.6 1.6[0.6;4] 2.5[0.6;8.8]
2.6[0.5;13.2 ]
2.7[0.4;17] 2.8[0.3;20.4]
2.9[0.3;23.6]
Cement- Cantilever FPD
5 173 1091.5 1.3[.3;5] 3.1[1.2;7.8]
3.9[7;18.8] 4.4[7;24.5] 4.8[6;30] 5.2[6;34.9]
Screw– cantilever FPD
5 120 560.2 0
32RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
Table-11: Survival
Retention& Type
No of studies
No of prosthesis
Total exposure
Annual /100 yr
5 yr 10 yr 15 yr 20 yr 25 yr
Cement -S 65 4719 19814.63 4.2[3.2;5..4]
14.5[11.4;18.3]
25.5[20.4;31.3]
35.1[28.3;42.6]
43.2[35.1;51.6]
51[38.2;64.8]
Screw-S 26 1005 7322.68 8.5[5.5;12.9]
26.6[19.6;35.1]
42[32.1;.52.5] 50[39.5;61.9] 55.7[43.3;67.3]
59.3[45.9;71.3]
MC-S 2 333 1955.14 7.8[0;9.98] 31.3[4.2;82.7]
54.3[6.3;95.4] 67.8[6.5;98.4] 71.6[5.7;99.1]
87.2[7.8;9.98]
Cement - FPD
19 949 4206.4 4.5[[2.5;8.1]
12.8[6.9;22.7]
21.3[11.3;36.4]
29[15.6;47.5] 36.1[20.1;56] 41.8[24.1;61.9]
Screw-FPD
22 1506 8700.43 7.9[5.4;11.4]
21[13.9;30.5] 32.6[20.8;47.2]
42.6[26.9;59.9]
50.9[32.5;69.1]
57.1[37;75]
Cement- splinted
5 345 1502.6 2.2[1.1;4.5] 6.6[1.9;20.7] 9.4[1.6;39.1] 11.7[1.5;53] 13.9[1.5;63.4]
15.9[1.4;71.1]
Screw- splinted
6 398 1399.6 5.7[2.3;13.4]
23.5[10.8;43.8]
41.8[21.5;65.3]
56.1[33.2;76.6]
66.3[44.8;82.7]
72.8[53.9;85.9]
Cement- Cantilever FPD
5 173 1091.5 4.4[0.5;19] 12.8[1;68] 20.4[1.7;78.6] 24.5[2.7;78.9] 29.6[3.6;82.8]
35.6[4.2;87.3]
Screw– cantilever FPD
5 120 560.2 4.3[1.7;10.7]
12.5[5.8;24.8]
18.7[7.1;40.7] 22.9[8;50.4] 26.1[8.4;57.4]
28.6[8.7;62.9]
33RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
Table-12: Event free
Retention& Type
No of studies
No of prosthesis
Total exposure
Annual /100 yr
5 yr etd 10 yr etd 15 yr etd 20 yr etd 25 yr etd
Cement -S
65 4719 19814.63 95.6[92.8;98.4]
79.9[71.6;88.3] 66.5[53.9;79] 57.9[43.7;72.2]
51.4[36.7;66] 46[31.6;60.4]
Screw-S 26 1005 7322.68 90.9[87.6;93.4]
72.7[64.2;79.7] 57.6[46.9;67.5]
48.8[37.3;60.4]
43.9[31.8;56.7]
40.2[27.6;54.2]
MC-S 2 333 1955.14 92.3[62.1;99.9]
85.5[10.4;99.9] 78.3[2.3;99.8]
70.8[0.7;99.9]
62.8[0.2;99.9]
54.7[0.1;99.9]
Cement - FPD
19 949 4206.4 95.1[91.5;97.2]
85.12[74.62;91.7]
74.7[59.1;85.9]
65.2[47.6;79.5]
56.9[39.3;72.9]
50.7[33.6;67.6]
Screw-FPD
22 1506 8700.43 91.6[88.1;94.1]
77.6[68.2;84.9] 65.6[51.4;77.5]
55.4[38.7;71] 47.2[29.8;65.4]
41.6[24.1;61.5]
Cement- splinted
5 345 1502.6 97.4[94.9;98.7]
93.1[70;98.8] 89.9[47.3;98.9]
87.1[32.5;99] 84.6[22.7;99] 82.2[16.2;99.1]
Screw- splinted
6 398 1399.6 94.2[85.3;97.8]
76[53.5;89.7] 57.1[32.5;78.7]
42.8[22.4;66] 33.2[17.4;54.1]
28.4[15.3;46.5]
Cement- Cantilever FPD
5 173 1091.5 95.6[65.8;99.6]
87[30.2;99] 79.1[19.5;98.3]
74.4[18.4;97.4]
68.9[14.6;96.6]
45.6[36.5;55]
Screw– cantilever FPD
5 120 560.2 95.7[89.3;98.3]
87.5[75.2;94.2] 81.3[59.3;92.9]
77.1[49.6;92] 73.9[42.6;91.6]
71.4[37.1;91.3]
34
Table-13.Failure rate by prosthesis and implant characteristics
Variables Retention type
No of studies
No of prosthesis
Exposure time[yr]
No of Failure events
Estimated event rate/100 yr
P Value
Single crown Cement 65
26
2
4711
1005
333
19774.63
7322.68
1955.14
80
16
6
1.3
1.8
1.4
0.14
Screw
Mechano- chemical
Splinted crown
Cement 5
6
1
345
398
28
1502.6
1399.6
84
4
2
0
1.2
0.5
0.6
Screw
Mechano- chemical
Cantilever FPD
Cement 5
5
173
120
1091.5
560.2
3
0
1.3
0.3
Screw
FPD Cement 19
22
949
1506
4206.4
8700.43
26
38
1.4
1.5
Screw Titanium Abutment
Cement
Screw
8
3
487
87
1679.21
505
4
0
0.2
0
0.3747 Ceramic abutment
Cement
Screw
4
3
206
158
1866
694
4
0
0.2
0
PFM Cem
ent
Scre
w
9
7
304
310
1335.2
1305.12
4
1
0.3
0.1
0.2854
All-Ceramic Cement
Screw
4
3
225
61
1259.4
181
3
0
0.2
0.1
Internal hex Cement
Screw
8
2
992
91
3018.07
366.94
11
0
0.4
0
0.3416 External hex Cem
ent
Scre
w
7
2
654
20
1279
28
8
1
0.6
3.6
Anterior Cement 7 270 1052.1 4 0.4
35RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
Screw 2 78 183.94 0 0
0.6183 Posterior Cem
ent
Scre
w
7
5
739
346
2137.29
1648.94
5
3
0.7
0.9
Permanent cement
Cement 8 472 2083.64 6 1.3
0.110 Temporary cement
Cement 9 857 2506.76 15 1.8
Table-14. Survival rate by prosthesis and implant characteristics
Variables Retention type
No of studies
No of prosthesis
Exposure time
No of events
Estimated event rate/100 yr
P Value
Single crown Cement
Screw
Mechano- chemical
65
26
2
4711
1005
333
19774.63
7322.68
1955.14
586 260
62
4.2[3.2;5.4]
8.5[5.5;12.9]
7.8[0;9.98]
0.0266*
0.0382*
0.0338*
Splinted crown
Cement
Screw
5
6
345
398
1502.6
1399.6
32 56
2.2[1.1;4.5]
5.7[2.3;13.4]
Cantilever FPD
Cement
Screw
5
5
173
120
1091.5
560.2
41 13
4.4[0.5;19]
4.3[1.7;10.7]
FPD Cement
Screw
19
22
949
1506
4206.4
8700.43
172 447
4.5[2.5;8.1]
7.9[5.4;11.4]
Titanium Abutment
Cement Screw
8
3
487
87
1679.21
505
47 0
2.8
0
0.8993 Cera
mic abutment
Cement Screw
4
3
206
158
1866
694
4 0
0.2
0 PFM Cement
Screw 9
7
304
310
1335.2
1305.12
55 78
4.11
5.9
0.2681
All-Ceramic Cement Screw
4
3
225
61
1259.4
181
35 8
2.77
4.4
36RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
Internal Hex Cement
Screw 8
2
992
91
3018.07
366.94
76 32
2.5 8.7
0.0522 External hex Cement
Screw 7
2
654
20
1279
28
84 20
6.5
7.1 Anterior Cement
Screw
7
2
270
78
1052.1
183.94
12 14
1.14
7.6
0.0385*
Posterior Cement
Screw
7
5
739
346
2137.29
1648.94
71 70
3.3
4.2
Permanentcement
Cement 8 472 2083.64 107 5.1 0.923
Temporarycement
Cement 9 857 2506.76 121 4.8
Table-15:MinorandMajorcomplicationevents
Retention type
Estimated event rate/100 yr
P Value
Single crown- Minor complications
Screw
Cement
8.3[5.7;11.8]
3.4[2.5;4.6]
0.0012*
0.6977 0.4460
0.1643
Single crown- Major complications
Screw
Cemen
t
3.8[2.4;6]
2.0[1.5;2.5]
FPD- Minor complications
Screw
Cement
6.8[3.9;11.4]
4.3[2.4;7.5] FPD-Major complications
Screw
Cement
3.0[2.1;4.4]
1.5[0.8;2.7]
37RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
Figure1:Meta–analysisoffailure,survivalandeventfreerateofsinglecrown,splintedcrown,CantileverFPD,FPD.
Annual failure rate- Single crown screw retained
Model Study nam e Subgroup within study Statistics for each study Event rate and 95% C I Weight (Fixed) Weight (Random ) Residual (Fixed)
Event Lower Upper Relative Relative Relative Relative S td S td S td S td S td S td rate lim it lim it Z-Value p-Value weight weight weight weight Residual Residual Residual Residual Residual Residual
Vigolo, 2012 R C T 0.005556 0.000011 0.736499 -1.635832 0.101875 0.73 0.73 -0.40 -0.40
Avivi-Arber, 1996 Pros 0.019231 0.001192 0.243612 -2.753358 0.005899 3.58 3.58 -0.02 -0.02
Balshi, 1996 Pros 0.022727 0.001407 0.277410 -2.629174 0.008559 3.57 3.57 0.11 0.11
Bragger 2005 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 3.04 3.04 1.51 1.51
Brown, 2011 Pros 0.018519 0.001149 0.236411 -2.781304 0.005414 3.59 3.59 -0.04 -0.04
Cabello, 2013 Pros 0.038462 0.002363 0.403194 -2.231889 0.025622 3.51 3.51 0.49 0.49
Cho, 2004 Pros 0.012500 0.000777 0.170774 -3.070295 0.002138 3.61 3.61 -0.33 -0.33
Henry, 1996 Pros 0.003774 0.000170 0.077908 -3.519880 0.000432 2.91 2.91 -1.07 -1.07
Kourtis 2004 Pros 0.062500 0.003793 0.538588 -1.854075 0.063728 3.43 3.43 0.84 0.84
Kreissl, 2007 Pros 0.010638 0.000662 0.148561 -3.187938 0.001433 3.61 3.61 -0.45 -0.45
Mericske-Stern, 2001 Pros 0.007003 0.000688 0.067409 -4.172560 0.000030 5.18 5.18 -0.90 -0.90
Montero, 2012 Pros 0.005882 0.000367 0.087074 -3.616702 0.000298 3.63 3.63 -0.88 -0.88
Santing, 2013 Pros 0.014706 0.000914 0.195875 -2.951224 0.003165 3.60 3.60 -0.21 -0.21
Schropp, 2008 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 3.04 3.04 1.51 1.51
Wannfors, 1999 Pros 0.011111 0.000691 0.154296 -3.156263 0.001598 3.61 3.61 -0.41 -0.41
Watson, 1999 Pros 0.031250 0.001926 0.350276 -2.389954 0.016850 3.54 3.54 0.34 0.34
Zembic, 2013 Pros 0.125000 0.007325 0.734442 -1.287099 0.198060 3.20 3.20 1.32 1.32
Bambini, 2001 Retro 0.015152 0.000941 0.200794 -2.929291 0.003397 3.60 3.60 -0.19 -0.19
Becker, 1995 Retro 0.020000 0.001240 0.251266 -2.724274 0.006444 3.58 3.58 0.01 0.01
Camargos Gde, 2012 Retro 0.009434 0.000588 0.133659 -3.275287 0.001056 3.62 3.62 -0.53 -0.53
Cha 2013 Retro 0.018868 0.004724 0.072287 -5.534935 0.000000 14.34 14.34 -0.06 -0.06
Cordioli, 1994 Retro 0.007353 0.000458 0.106860 -3.455777 0.000549 3.63 3.63 -0.71 -0.71
Engquist, 1995 Retro 0.007463 0.000465 0.108308 -3.445072 0.000571 3.63 3.63 -0.70 -0.70
Jemt, 2009 Retro 0.026316 0.001626 0.309619 -2.519484 0.011753 3.56 3.56 0.21 0.21
Krennmair, 2002 Retro 0.009259 0.000577 0.131461 -3.288856 0.001006 3.62 3.62 -0.55 -0.55
Scholander, 1999 Retro 0.166667 0.009511 0.806422 -1.038888 0.298857 3.04 3.04 1.51 1.51
Fixed 0.019655 0.011666 0.032934 -14.463112 0.000000 Random 0.019655 0.011666 0.032934 -14.463112 0.000000 -0.50 -0.25 0.00 0.25 0.50
38RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
Annual Survival rate- Single crown screw retained
Model Groupby Subgroupwithinstudy
Studyname Subgroupwithinstudy Statisticsfor eachstudy Eventrateand95% CI
39RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
Annual Event free rate- Single crown screw retained
Model Groupby
Subgroupwithinstudy
Studyname Subgroupwithinstudy Statistics for eachstudy Eventrate and95% CI
Event Lower Upper
Pros
Avivi-Arber, 1996
Pros
rate limit limit
0.950000 0.758753 0.991363
Z-Value p-Value
3.208628 0.001334 Pros Balshi, 1996 Pros 0.913043 0.697090 0.979553 3.036186 0.002396 Pros Bragger 2005 Pros 0.995455 0.000000 1.000000 0.512659 0.608190 Pros Brown, 2011 Pros 0.730769 0.532939 0.865891 2.258394 0.023921 Pros Cabello, 2013 Pros 0.961538 0.596806 0.997637 2.231889 0.025622 Pros Cho, 2004 Pros 0.992523 0.776466 0.999803 2.629835 0.008543 Pros Henry, 1996 Pros 0.886792 0.811160 0.934576 6.714735 0.000000 Pros Kourtis 2004 Pros 0.999617 0.000000 1.000000 0.407428 0.683694 Pros Kreissl, 2007 Pros 0.982143 0.861192 0.997953 3.599380 0.000319 Pros Mericske-Stern, 2001 Pros 0.946312 0.881676 0.976578 6.531975 0.000000 Pros Montero, 2012 Pros 0.939930 0.864164 0.974674 5.989567 0.000000 Pros Santing, 2013 Pros 0.985294 0.804125 0.999086 2.951224 0.003165 Pros Schropp, 2008 Pros 0.833333 0.193578 0.990489 1.038888 0.298857 Pros Wannfors, 1999 Pros 0.772727 0.626844 0.873122 3.401848 0.000669 Pros Watson, 1999 Pros 0.750000 0.482486 0.906133 1.842429 0.065412 Pros Zembic, 2013 Pros 0.875000 0.265558 0.992675 1.287099 0.198060 Fixed Pros 0.882594 0.847463 0.910489 13.074992 0.000000 Random Pros 0.895853 0.844550 0.931596 9.179229 0.000000 RCT Vigolo, 2012 RCT 0.994444 0.263501 0.999989 1.635832 0.101875 Fixed RCT 0.994444 0.263501 0.999989 1.635832 0.101875 Random RCT 0.994444 0.248300 0.999990 1.615084 0.106293 Retro Bambini, 2001 Retro 0.983051 0.798391 0.998824 2.964902 0.003028 Retro Becker, 1995 Retro 0.812500 0.608574 0.923533 2.803830 0.005050 Retro Camargos Gde, 2012 Retro 0.946154 0.840520 0.983217 4.665279 0.000003 Retro Cha 2013 Retro 0.913208 0.842540 0.953895 6.821540 0.000000 Retro Cordioli, 1994 Retro 0.958541 0.874303 0.987155 5.124839 0.000000 Retro Engquist, 1995 Retro 0.893939 0.793822 0.948590 5.332297 0.000000 Retro Jemt, 2009 Retro 0.971429 0.679924 0.998166 2.492495 0.012685 Retro Krennmair, 2002 Retro 0.955679 0.853565 0.987619 4.601219 0.000004 Retro Scholander, 1999 Retro 0.833333 0.193578 0.990489 1.038888 0.298857 Fixed Retro 0.917794 0.884706 0.942008 12.611398 0.000000 Random Retro 0.924363 0.875886 0.954880 8.934533 0.000000 Fixed Overall 0.898202 0.874592 0.917784 18.143504 0.000000 Random Overall 0.910954 0.865173 0.942227 9.771934 0.000000
-1.00 -0.50 0.00 0.50 1.00
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
40RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual Survival rate- FPD screw retained
Model Groupby
Subgroupwithinstudy
Study name Subgroupwithinstudy Statistics for eachstudy Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
CCT Jacobs, 2010 CCT 0.038194 0.007171 0.179197 -3.710016 0.000207 CCT Jemt, 2003 CCT 0.107937 0.051770 0.211450 -5.201697 0.000000 CCT Nissan, 2011 CCT 0.129187 0.054366 0.276834 -3.945301 0.000080 Fixed CCT 0.103066 0.060796 0.169424 -7.389126 0.000000 Random CCT 0.092914 0.035435 0.222152 -4.355296 0.000013 Pros Bischof, 2006 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 Pros Bragger 2005 Pros 0.060000 0.009982 0.287794 -2.922333 0.003474 Pros Cho, 2004 Pros 0.061765 0.023939 0.150163 -5.400776 0.000000 Pros Hosny, 2000 Pros 0.003205 0.000022 0.324138 -2.247721 0.024594 Pros Jemt, 1993 Pros 0.185106 0.118927 0.276553 -5.580980 0.000000 Pros Kourtis 2004 Pros 0.001542 0.000079 0.029354 -4.265058 0.000020 Pros Kreissl, 2007 Pros 0.062500 0.003793 0.538588 -1.854075 0.063728 Pros Lekholm, 1999 Pros 0.021320 0.008217 0.054175 -7.758086 0.000000 Pros Lindh, 2001 Pros 0.153846 0.078851 0.278597 -4.435370 0.000009 Pros Mertens, 2011 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 Pros Nedir, 2006 Pros 0.007353 0.000145 0.274710 -2.443604 0.014541 Pros Ortorp, 2008 Pros 0.040000 0.016446 0.094063 -6.822091 0.000000 Fixed Pros 0.092336 0.068612 0.123178 -13.877971 0.000000 Random Pros 0.062391 0.034410 0.110521 -8.505211 0.000000 Prosp Balleri 2010 Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 Fixed Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 Random Prosp 0.033333 0.001486 0.444065 -2.100091 0.035721 RCT Andersson, 2003 RCT 0.023529 0.001046 0.356726 -2.328449 0.019888 Fixed RCT 0.023529 0.001046 0.356726 -2.328449 0.019888 Random RCT 0.023529 0.000780 0.426552 -2.129078 0.033248 Retro Aparicio 2001 Retro 0.179131 0.077889 0.360519 -3.143446 0.001670 Retro Jemt 1992 Retro 0.157480 0.103906 0.231541 -6.884352 0.000000 Retro Malo 2000 Retro 0.020833 0.001291 0.259416 -2.693957 0.007061 Retro Naert, 1992 Retro 0.096260 0.062491 0.145446 -9.364651 0.000000 Retro Thomsson, 2008 Retro 0.015152 0.000941 0.200794 -2.929291 0.003397 Fixed Retro 0.122733 0.092934 0.160398 -12.374040 0.000000 Random Retro 0.105439 0.049360 0.211084 -5.111971 0.000000 Fixed Overall 0.105274 0.087248 0.126509 -20.187424 0.000000 Random Overall 0.076785 0.045549 0.126600 -8.774542 0.000000
-1.00
-0.50
0.00
0.50
1.00
Annual Failure rate- FPD screw retained
Model Groupby
Subgroupwithinstudy
Study name Subgroupwithinstudy Statistics for eachstudy Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
CCT Jacobs, 2010 CCT 0.013514 0.000840 0.182466 -3.013245 0.002585 CCT Jemt, 2003 CCT 0.006349 0.000285 0.125188 -3.185672 0.001444 CCT Nissan, 2011 CCT 0.012821 0.000797 0.174501 -3.051781 0.002275 Fixed CCT 0.010682 0.002037 0.054034 -5.327979 0.000000 Random CCT 0.010682 0.002037 0.054034 -5.327979 0.000000 Pros Bischof, 2006 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 Pros Bragger 2005 Pros 0.023810 0.001473 0.287375 -2.594443 0.009474 Pros Cho, 2004 Pros 0.007246 0.000452 0.105451 -3.466324 0.000528 Pros Hosny, 2000 Pros 0.010204 0.000635 0.143238 -3.218263 0.001290 Pros Jemt, 1993 Pros 0.005263 0.000328 0.078521 -3.696708 0.000218 Pros Kourtis 2004 Pros 0.001767 0.000110 0.027584 -4.476852 0.000008 Pros Kreissl, 2007 Pros 0.062500 0.003793 0.538588 -1.854075 0.063728 Pros Lekholm, 1999 Pros 0.012690 0.003678 0.042835 -6.840679 0.000000 Pros Lindh, 2001 Pros 0.028846 0.005821 0.130947 -4.244253 0.000022 Pros Mertens, 2011 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 Pros Nedir, 2006 Pros 0.014286 0.000888 0.191192 -2.972503 0.002954 Pros Ortorp, 2008 Pros 0.000833 0.000002 0.291377 -2.240881 0.025034 Fixed Pros 0.017192 0.008780 0.033392 -11.653315 0.000000 Random Pros 0.017192 0.008780 0.033392 -11.653315 0.000000 Prosp Balleri 2010 Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 Fixed Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 Random Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 RCT Andersson, 2003 RCT 0.027778 0.001715 0.322082 -2.478848 0.013181 Fixed RCT 0.027778 0.001715 0.322082 -2.478848 0.013181 Random RCT 0.027778 0.001715 0.322082 -2.478848 0.013181 Retro Aparicio 2001 Retro 0.016667 0.001035 0.217152 -2.859126 0.004248 Retro Jemt 1992 Retro 0.003906 0.000244 0.059299 -3.910605 0.000092 Retro Malo 2000 Retro 0.020833 0.001291 0.259416 -2.693957 0.007061 Retro Naert, 1992 Retro 0.007093 0.001374 0.035771 -5.879303 0.000000 Retro Thomsson, 2008 Retro 0.015152 0.000941 0.200794 -2.929291 0.003397 Fixed Retro 0.009612 0.003335 0.027382 -8.530584 0.000000 Random Retro 0.009612 0.003335 0.027382 -8.530584 0.000000 Fixed Overall 0.014842 0.008850 0.024790 -15.718108 0.000000 Random Overall 0.014635 0.008023 0.026548 -13.576574 0.000000
-0.50
-0.25
0.00
0.25
0.50
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
41RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual event free rate- FPD screw retained
Model Groupby
Subgroupwithinstudy
Study name Subgroupwithinstudy Statistics for eachstudy Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
CCT Jacobs, 2010 CCT 0.961806 0.820803 0.992829 3.710016 0.000207 CCT Jemt, 2003 CCT 0.885714 0.781010 0.943950 5.171040 0.000000 CCT Nissan, 2011 CCT 0.870813 0.723166 0.945634 3.945301 0.000080 Fixed CCT 0.893598 0.826588 0.936697 7.363886 0.000000 Random CCT 0.904259 0.777400 0.962325 4.423640 0.000010 Pros Bischof, 2006 Pros 0.833333 0.193578 0.990489 1.038888 0.298857 Pros Bragger 2005 Pros 0.940000 0.712206 0.990018 2.922333 0.003474 Pros Cho, 2004 Pros 0.938235 0.849837 0.976061 5.400776 0.000000 Pros Hosny, 2000 Pros 0.996795 0.675862 0.999978 2.247721 0.024594 Pros Jemt, 1993 Pros 0.814894 0.723447 0.881073 5.580980 0.000000 Pros Kourtis 2004 Pros 0.998458 0.970646 0.999921 4.265058 0.000020 Pros Kreissl, 2007 Pros 0.937500 0.461412 0.996207 1.854075 0.063728 Pros Lekholm, 1999 Pros 0.965990 0.929306 0.983966 8.513610 0.000000 Pros Lindh, 2001 Pros 0.817308 0.688867 0.900393 4.174726 0.000030 Pros Mertens, 2011 Pros 0.833333 0.193578 0.990489 1.038888 0.298857 Pros Nedir, 2006 Pros 0.992647 0.725290 0.999855 2.443604 0.014541 Pros Ortorp, 2008 Pros 0.959167 0.904865 0.983054 6.843212 0.000000 Fixed Pros 0.904139 0.873848 0.927757 14.249805 0.000000 Random Pros 0.931230 0.881320 0.961078 8.501217 0.000000 Prosp Balleri 2010 Prosp 0.966667 0.633695 0.997947 2.341017 0.019231 Fixed Prosp 0.966667 0.633695 0.997947 2.341017 0.019231 Random Prosp 0.966667 0.562179 0.998476 2.117155 0.034247 RCT Andersson, 2003 RCT 0.976471 0.643274 0.998954 2.328449 0.019888 Fixed RCT 0.976471 0.643274 0.998954 2.328449 0.019888 Random RCT 0.976471 0.579112 0.999202 2.143574 0.032067 Retro Aparicio 2001 Retro 0.820869 0.639481 0.922111 3.143446 0.001670 Retro Jemt 1992 Retro 0.842520 0.768459 0.896094 6.884352 0.000000 Retro Malo 2000 Retro 0.979167 0.740584 0.998709 2.693957 0.007061 Retro Naert, 1992 Retro 0.896647 0.846367 0.931798 9.324532 0.000000 Retro Thomsson, 2008 Retro 0.984848 0.799206 0.999059 2.929291 0.003397 Fixed Retro 0.874167 0.836332 0.904257 12.369371 0.000000 Random Retro 0.890984 0.787126 0.947547 5.191462 0.000000 Fixed Overall 0.891737 0.870608 0.909774 20.432194 0.000000 Random Overall 0.918468 0.869205 0.950238 8.993620 0.000000
-1.00
-0.50
0.00
0.50
1.00
Annual Failure rate- Splinted crown- screw retained
Model Groupby Subgroupwithinstudy
Studyname Subgroupwithinstudy Statistics for eachstudy Eventrate and95%
CI Event Lower Upper rate limit limit Z-Value p-Value
os Esposito, 2014 os 0.031250 0.001926 0.350276 -2.389954 0.016850
Fixed os 0.031250 0.001926 0.350276 -2.389954 0.016850
Random os 0.031250 0.001926 0.350276 -2.389954 0.016850
Pros Gulje, 2013 Pros 0.021277 0.005328 0.081081 -5.356606 0.000000 Pros Balshi, 1996 Pros 0.019231 0.001192 0.243612 -2.753358 0.005899 Pros Kourtis 2004 Pros 0.002475 0.000155 0.038284 -4.236636 0.000023 Pros Kreissl, 2007 Pros 0.013514 0.000840 0.182466 -3.013245 0.002585
Fixed Pros 0.014425 0.005061 0.040408 -7.834642 0.000000 Random Pros 0.014425 0.005061 0.040408 -7.834642 0.000000
Retro Bambini, 2001 Retro 0.017857 0.001108 0.229623 -2.808198 0.004982 Fixed Retro 0.017857 0.001108 0.229623 -2.808198 0.004982
Random Retro 0.017857 0.001108 0.229623 -2.808198 0.004982 Fixed Overall 0.016088 0.006393 0.039899 -8.643384 0.000000
Random Overall 0.016088 0.006393 0.039899 -8.643384 0.000000
-0.50
-0.25
0.00
0.25
0.50
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
42RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual Survival rate- Splinted crown- screw retained
Model Groupby
Subgroupwithinstudy Studyname Subgroupwithinstudy Statisticsfor eachstudy Eventrateand95% CI
Event Lower Upper rate limit limit Z-Value p-Value
os Esposito,2014 os 0.044444 0.003975 0.351510 -2.448754 0.014335
Fixed os 0.044444 0.003975 0.351510 -2.448754 0.014335
Random os 0.044444 0.001787 0.547122 -1.846204 0.064863
Pros Gulje,2013 Pros 0.159574 0.098552 0.247986 -5.898870 0.000000 Pros Balshi,1996 Pros 0.053333 0.009748 0.243820 -3.231581 0.001231 Pros Kourtis2004 Pros 0.027039 0.011711 0.061184 -8.239383 0.000000 Pros Kreissl,2007 Pros 0.027778 0.003899 0.172561 -3.505620 0.000456
Fixed Pros 0.088355 0.058925 0.130444 -10.471005 0.000000 Random Pros 0.056237 0.016814 0.171936 -4.428083 0.000010
Retro Bambini,2001 Retro 0.061728 0.013538 0.239765 -3.403019 0.000666 Fixed Retro 0.061728 0.013538 0.239765 -3.403019 0.000666
Random Retro 0.061728 0.004616 0.482773 -2.010903 0.044336 Fixed Overall 0.084558 0.057501 0.122690 -11.255774 0.000000
Random Overall 0.055679 0.019879 0.146324 -5.199319 0.000000
-0.50
-0.25
0.00
0.25
0.50
Annual event free rate- Splinted crown- screw retained
Model Groupby Subgroupwithinstudy
Study name Subgroupwithinstudy Statistics for eachstudy Event rate and 95%
CI Event Lower Upper rate limit limit Z-Value p-Value
os Esposito, 2014 os 0.955556 0.648490 0.996025 2.448754 0.014335
Fixed os 0.955556 0.648490 0.996025 2.448754 0.014335
Random os 0.955556 0.414220 0.998473 1.761047 0.078230
Pros Gulje, 2013 Pros 0.819149 0.728173 0.884506 5.637066 0.000000 Pros Balshi, 1996 Pros 0.946667 0.756180 0.990252 3.231581 0.001231 Pros Kourtis 2004 Pros 0.972961 0.938816 0.988289 8.239383 0.000000 Pros Kreissl, 2007 Pros 0.972222 0.827439 0.996101 3.505620 0.000456 Fixed Pros 0.899765 0.854632 0.932000 10.163661 0.000000 Random Pros 0.941930 0.807431 0.984314 4.036581 0.000054 Retro Bambini, 2001 Retro 0.938272 0.760235 0.986462 3.403019 0.000666 Fixed Retro 0.938272 0.760235 0.986462 3.403019 0.000666 Random Retro 0.938272 0.469473 0.996184 1.875694 0.060697 Fixed Overall 0.904907 0.864119 0.934380 10.956172 0.000000 Random Overall 0.943086 0.839884 0.981255 4.784000 0.000002
-1.00
-0.50
0.00
0.50
1.00
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
43RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual failure rate- Cantilever FPD- screw retained
Model Groupby Subgroupwithinstudy
Study name Subgroupwithinstudy Statistics for eachstudy Event rate and 95% CI
Event rate
Lower limit
Upper limit
Z-Value p-Value
Prosp Balleri 2010 Prosp 0.071429 0.004315 0.577249 -1.747718 0.080513 Prosp Bischof, 2006 Prosp 0.041667 0.002556 0.424563 -2.170448 0.029973 Prosp Kourtis 2004 Prosp 0.006410 0.000400 0.094260 -3.554791 0.000378 Prosp Kreissl, 2007 Prosp 0.020833 0.001291 0.259416 -2.693957 0.007061 Fixed Prosp 0.024827 0.006172 0.094506 -5.099261 0.000000 Random Prosp 0.024827 0.006172 0.094506 -5.099261 0.000000 retro Beckerr 2004 retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Fixed retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Random retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Fixed Overall 0.033832 0.009701 0.111245 -5.157336 0.000000 Random Overall 0.034868 0.009191 0.123344 -4.787186 0.000002
-0.50
-0.25
0.00
0.25
0.50
Annual Survival rate- Cantilever FPD- screw retained
Model Groupby Subgroupwithinstudy
Study name Subgroupwithinstudy Statistics for eachstudy Event rate and 95% CI
Event rate
Lower limit
Upper limit
Z-Value p-Value
Prosp Balleri 2010 Prosp 0.071429 0.004315 0.577249 -1.747718 0.080513 Prosp Bischof, 2006 Prosp 0.041667 0.002556 0.424563 -2.170448 0.029973 Prosp Kourtis 2004 Prosp 0.016940 0.003043 0.088656 -4.598558 0.000004 Prosp Kreissl, 2007 Prosp 0.060870 0.011595 0.263684 -3.137460 0.001704 Fixed Prosp 0.037413 0.013530 0.099217 -6.110740 0.000000 Random Prosp 0.037413 0.013530 0.099217 -6.110740 0.000000 retro Beckerr 2004 retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Fixed retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Random retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Fixed Overall 0.042925 0.016510 0.107001 -6.191768 0.000000 Random Overall 0.042925 0.016510 0.107001 -6.191768 0.000000
-0.50
-0.25
0.00
0.25
0.50
Annual Event free rate- Cantilever FPD- screw retained
Model Group by
Subgroup within study
Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
Prosp Balleri 2010 Prosp 0.928571 0.422751 0.995685 1.747718 0.080513
Prosp Bischof, 2006 Prosp 0.958333 0.575437 0.997444 2.170448 0.029973
Prosp Kourtis 2004 Prosp 0.983060 0.911344 0.996957 4.598558 0.000004
Prosp Kreissl, 2007 Prosp 0.939130 0.736316 0.988405 3.137460 0.001704
Fixed Prosp 0.962587 0.900783 0.986470 6.110740 0.000000
Random Prosp 0.962587 0.900783 0.986470 6.110740 0.000000
retro Beckerr 2004 retro 0.875000 0.265558 0.992675 1.287099 0.198060
Fixed retro 0.875000 0.265558 0.992675 1.287099 0.198060
Random retro 0.875000 0.265558 0.992675 1.287099 0.198060
Fixed Overall 0.957075 0.892999 0.983490 6.191768 0.000000
Random Overall 0.957075 0.892999 0.983490 6.191768 0.000000
-1.00 -0.50 0.00 0.50 1.00
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
44RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual Failure rate- Single crown(Mechano-chemical)
Model Studyname Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper
rate limit limit Z-Value p-Value
Andersen 2001 Prosp 0.062500 0.003793 0.538588 -1.854075 0.063728
Uradenta 2010 Retros 0.003125 0.000448 0.021451 -5.809752 0.000000
Fixed 0.008165 0.001645 0.039507 -5.847501 0.000000
Random 0.011838 0.000612 0.189817 -2.916576 0.003539
-1.00 -0.50 0.00 0.50 1.00
Annual success rate- Single crown(Mechano-chemical)
Model Subgroup within study Statistics for each study Ev ent rate and 95% CI
Ev ent Lower Upper
rate limit limit Z-Value p-Value
Andersen 200P1rosp 0.2000000.0377500.614365 -1.4671160.142344
Uradenta 201R0 etros 0.0286440.0151490.053506-10.6125330.000000
Fixed 0.0359560.0197860.064473-10.4987470.000000
Random 0.0667270.0089970.360227 -2.5054670.012229
-1.00 -0.50 0.00 0.50 1.00
Annual event free rate- Single crown(Mechano-chemical)
Model Subgroup within study Statistics for each study Ev ent rate and 95% CI
Ev ent Lower Upper
rate limit limit Z-Value p-Value
Andersen 200P1rosp 0.0625000.0037930.538588-1.8540750.063728
Uradenta 201R0etros 0.8610000.8190370.89448611.3907480.000000
Fixed 0.8544350.8112120.88911511.1209150.000000
Random 0.4477760.0096880.985340-0.0930230.925885
-1.00 -0.50 0.00 0.50 1.00
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
45RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual failure rate- Single crown cemented
Model Group by
Subgroup within study
Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
CCT Andersen, 2001 CCT 0.010 0.001 0.136 -3.261 0.001 CCT Bergenblock, 2012 CCT 0.003 0.000 0.185 -2.651 0.008 CCT Gotfredsen, 2012 CCT 0.024 0.001 0.287 -2.594 0.009 Fixed CCT 0.012 0.002 0.065 -4.876 0.000 Random CCT 0.012 0.002 0.065 -4.876 0.000 PROS Andersson, 1998 PROS 0.009 0.001 0.107 -3.592 0.000 PROS Avivi-Arber, 1996 PROS 0.025 0.002 0.298 -2.558 0.011 PROS Behneke 2000 PROS 0.014 0.000 0.587 -1.810 0.070 PROS Bischof, 2006 PROS 0.004 0.000 0.046 -4.301 0.000 PROS Bragger 2005 PROS 0.007 0.000 0.108 -3.445 0.001 PROS Cabello, 2013 PROS 0.167 0.010 0.806 -1.039 0.299 PROS Cooper, 2007 PROS 0.010 0.001 0.136 -3.261 0.001 PROS Drago 2003 PROS 0.005 0.000 0.068 -3.808 0.000 PROS Glauser, 2004 PROS 0.009 0.001 0.129 -3.302 0.001 PROS Haas, 2002 PROS 0.010 0.001 0.090 -3.925 0.000 PROS Henry 1995 PROS 0.009 0.001 0.134 -3.275 0.001 PROS Hosseini, 2013 PROS 0.005 0.000 0.076 -3.726 0.000 PROS Karlsson, 1997 PROS 0.010 0.001 0.146 -3.203 0.001 PROS Kourtis, 2004 PROS 0.004 0.000 0.056 -3.954 0.000 PROS Lee, 2011 PROS 0.003 0.000 0.035 -4.675 0.000 PROS Linkenvicus 2009 PROS 0.071 0.004 0.577 -1.748 0.081 PROS Mericske-Stern, 2001 PROS 0.063 0.004 0.539 -1.854 0.064 PROS Mertens, 2011 PROS 0.016 0.001 0.206 -2.907 0.004 PROS Montero, 2012 PROS 0.102 0.013 0.496 -1.975 0.048 PROS Muftu, 1998 PROS 0.016 0.008 0.034 -10.775 0.000 PROS Ormianer, 2006 PROS 0.022 0.001 0.268 -2.662 0.008 PROS Palmer, 2000 PROS 0.031 0.002 0.350 -2.390 0.017 PROS Polizzi, 1999 PROS 0.006 0.000 0.367 -2.197 0.028 PROS Priest 1999 PROS 0.001 0.000 0.307 -2.216 0.027 PROS Romeo 2006 PROS 0.003 0.000 0.315 -2.267 0.023 PROS Santing, 2013 PROS 0.018 0.001 0.230 -2.808 0.005 PROS Scheller, 1998 PROS 0.004 0.000 0.085 -3.462 0.001 PROS Schropp, 2008 PROS 0.012 0.001 0.167 -3.088 0.002 PROS Schwarz, 2012 PROS 0.004 0.000 0.030 -5.240 0.000 PROS Turkyilmaz, 2006 PROS 0.014 0.001 0.191 -2.973 0.003 PROS Wannfors, 1999 PROS 0.014 0.001 0.182 -3.013 0.003 PROS Watson 1999 PROS 0.026 0.002 0.310 -2.519 0.012 PROS zembic 2013 PROS 0.013 0.001 0.178 -3.033 0.002 Fixed PROS 0.014 0.009 0.020 -20.309 0.000 Random PROS 0.014 0.009 0.020 -20.309 0.000 RCT Cannizzaro, 2013 RCT 0.006 0.000 0.091 -3.582 0.000 RCT Cannizzaro, 2008 RCT 0.005 0.000 0.069 -3.795 0.000 RCT Canullo, 2013 RCT 0.024 0.001 0.287 -2.594 0.009 RCT Pieri, 2011 RCT 0.012 0.001 0.167 -3.088 0.002 RCT Pozzi, 2014 RCT 0.006 0.000 0.083 -3.650 0.000 RCT Vigolo, 2012 RCT 0.006 0.000 0.737 -1.635 0.102 RCT Visser, 2011 RCT 0.005 0.000 0.080 -3.681 0.000 RCT Zembic, 2012 RCT 0.018 0.002 0.114 -3.990 0.000 Fixed RCT 0.010 0.004 0.025 -9.351 0.000 Random RCT 0.010 0.004 0.025 -9.351 0.000 RETRO Bonde, 2010 RETRO 0.009 0.001 0.127 -3.315 0.001 RETRO Camargos Gde, 2012 RETRO 0.025 0.002 0.298 -2.558 0.011 RETRO Cha 2013 RETRO 0.013 0.001 0.234 -2.704 0.007 RETRO Engquist, 1995 RETRO 0.033 0.002 0.366 -2.341 0.019 RETRO Hartlev, 2013 RETRO 0.011 0.001 0.149 -3.188 0.001 RETRO Jemt, 2009 RETRO 0.021 0.001 0.259 -2.694 0.007 RETRO Khraisat, 2008 RETRO 0.006 0.000 0.084 -3.642 0.000 RETRO Krennmair, 2002 RETRO 0.004 0.000 0.097 -3.248 0.001 RETRO Krennmair, 2010 RETRO 0.006 0.001 0.062 -4.224 0.000 RETRO Levine, 2007 RETRO 0.001 0.000 0.016 -4.945 0.000 RETRO Malo, 2000 RETRO 0.016 0.001 0.206 -2.907 0.004 RETRO Mangano, 2001 RETRO 0.006 0.000 0.091 -3.582 0.000 RETRO Romanos, 2000 RETRO 0.020 0.003 0.114 -4.157 0.000 RETRO Scholander, 1999 RETRO 0.002 0.000 0.034 -4.080 0.000 RETRO Schwartz-Arad, 1999 RETRO 0.007 0.000 0.101 -3.497 0.000 RETRO Singer, 1996 RETRO 0.028 0.002 0.322 -2.479 0.013 RETRO Sorrentino, 2012 RETRO 0.008 0.001 0.085 -3.896 0.000 RETRO Thomsson, 2008 RETRO 0.028 0.002 0.322 -2.479 0.013 RETRO Vanlioglu, 2013 RETRO 0.004 0.000 0.060 -3.899 0.000 RETRO Wennstrom, 2005 RETRO 0.011 0.001 0.151 -3.172 0.002 RETRO Yaltirik, 2011 RETRO 0.075 0.006 0.530 -1.872 0.061 Fixed RETRO 0.011 0.006 0.019 -15.053 0.000 Random RETRO 0.011 0.006 0.019 -15.053 0.000 Fixed Overall 0.012 0.009 0.017 -27.379 0.000 Random Overall 0.012 0.009 0.017 -27.379 0.000
-0.25
-0.13
0.00
0.13
0.25
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
46RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual survival rate- Single crown cemented
Model Group by Subgroup within study
Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
CCT Andersen, 2001 CCT 0.082 0.032 0.196 -4.733 0.000 CCT Bergenblock, 2012 CCT 0.017 0.003 0.102 -4.212 0.000 CCT Gotfredsen, 2012 CCT 0.050 0.007 0.282 -2.870 0.004 Fixed CCT 0.057 0.026 0.120 -6.785 0.000 PROS Andersson, 1998 PROS 0.016 0.002 0.103 -4.111 0.000 PROS Avivi-Arber, 1996 PROS 0.171 0.059 0.405 -2.590 0.010 PROS Behneke 2000 PROS 0.014 0.000 0.587 -1.810 0.070 PROS Bischof, 2006 PROS 0.015 0.004 0.053 -6.403 0.000 PROS Bragger 2005 PROS 0.025 0.006 0.107 -4.696 0.000 PROS Cabello, 2013 PROS 0.500 0.059 0.941 0.000 1.000 PROS Cooper, 2007 PROS 0.046 0.013 0.151 -4.533 0.000 PROS Drago 2003 PROS 0.009 0.001 0.062 -4.670 0.000 PROS Glauser, 2004 PROS 0.027 0.005 0.126 -4.273 0.000 PROS Haas, 2002 PROS 0.046 0.016 0.124 -5.502 0.000 PROS Henry 1995 PROS 0.115 0.053 0.234 -4.693 0.000 PROS Hosseini, 2013 PROS 0.058 0.026 0.125 -6.449 0.000 PROS Karlsson, 1997 PROS 0.128 0.058 0.256 -4.397 0.000 PROS Kourtis, 2004 PROS 0.010 0.002 0.052 -5.262 0.000 PROS Lee, 2011 PROS 0.043 0.023 0.081 -9.069 0.000 PROS Linkenvicus 2009 PROS 0.071 0.004 0.577 -1.748 0.081 PROS Mericske-Stern, 2001 PROS 0.034 0.001 0.677 -1.605 0.109 PROS Mertens, 2011 PROS 0.016 0.001 0.206 -2.907 0.004 PROS Montero, 2012 PROS 0.050 0.003 0.475 -2.029 0.042 PROS Muftu, 1998 PROS 0.012 0.005 0.027 -9.887 0.000 PROS Ormianer, 2006 PROS 0.036 0.004 0.260 -2.877 0.004 PROS Palmer, 2000 PROS 0.027 0.001 0.388 -2.245 0.025 PROS Polizzi, 1999 PROS 0.006 0.000 0.366 -2.198 0.028 PROS Priest 1999 PROS 0.008 0.001 0.061 -4.550 0.000 PROS Romeo 2006 PROS 0.016 0.002 0.132 -3.615 0.000 PROS Santing, 2013 PROS 0.025 0.002 0.223 -2.964 0.003 PROS Scheller, 1998 PROS 0.041 0.016 0.105 -6.161 0.000 PROS Schropp, 2008 PROS 0.025 0.004 0.157 -3.617 0.000 PROS Schwarz, 2012 PROS 0.140 0.101 0.191 -9.587 0.000 PROS Turkyilmaz, 2006 PROS 0.020 0.002 0.184 -3.163 0.002 PROS Wannfors, 1999 PROS 0.148 0.065 0.304 -3.728 0.000 PROS Watson 1999 PROS 0.083 0.017 0.326 -2.812 0.005 PROS zembic 2013 PROS 0.014 0.001 0.179 -3.067 0.002 Fixed PROS 0.066 0.055 0.080 -25.439 0.000 RCT Cannizzaro, 2013 RCT 0.025 0.006 0.094 -5.116 0.000 RCT Cannizzaro, 2008 RCT 0.046 0.019 0.106 -6.606 0.000 RCT Canullo, 2013 RCT 0.024 0.001 0.287 -2.594 0.009 RCT Pieri, 2011 RCT 0.025 0.004 0.157 -3.617 0.000 RCT Pozzi, 2014 RCT 0.006 0.000 0.083 -3.650 0.000 RCT Vigolo, 2012 RCT 0.026 0.002 0.310 -2.519 0.012 RCT Visser, 2011 RCT 0.030 0.009 0.093 -5.703 0.000 RCT Zembic, 2012 RCT 0.175 0.097 0.296 -4.444 0.000 Fixed RCT 0.066 0.043 0.098 -11.913 0.000 RETRO Bonde, 2010 RETRO 0.027 0.006 0.124 -4.317 0.000 RETRO Camargos Gde, 2012 RETRO 0.025 0.002 0.298 -2.558 0.011 RETRO Cha 2013 RETRO 0.067 0.017 0.231 -3.606 0.000 RETRO Engquist, 1995 RETRO 0.033 0.002 0.366 -2.341 0.019 RETRO Hartlev, 2013 RETRO 0.063 0.020 0.181 -4.450 0.000 RETRO Jemt, 2009 RETRO 0.009 0.000 0.417 -2.109 0.035 RETRO Khraisat, 2008 RETRO 0.034 0.011 0.102 -5.671 0.000 RETRO Krennmair, 2002 RETRO 0.101 0.054 0.181 -6.353 0.000 RETRO Krennmair, 2010 RETRO 0.033 0.012 0.087 -6.376 0.000 RETRO Levine, 2007 RETRO 0.023 0.013 0.041 -12.564 0.000 RETRO Malo, 2000 RETRO 0.097 0.032 0.261 -3.677 0.000 RETRO Mangano, 2001 RETRO 0.014 0.002 0.084 -4.494 0.000 RETRO Romanos, 2000 RETRO 0.008 0.001 0.121 -3.353 0.001 RETRO Scholander, 1999 RETRO 0.028 0.014 0.057 -9.371 0.000 RETRO Schwartz-Arad, 1999 RETRO 0.069 0.029 0.156 -5.557 0.000 RETRO Singer, 1996 RETRO 0.088 0.018 0.341 -2.731 0.006 RETRO Sorrentino, 2012 RETRO 0.008 0.001 0.085 -3.896 0.000 RETRO Thomsson, 2008 RETRO 0.028 0.002 0.322 -2.479 0.013 RETRO Vanlioglu, 2013 RETRO 0.002 0.000 0.080 -3.299 0.001 RETRO Wennstrom, 2005 RETRO 0.009 0.000 0.168 -2.968 0.003 RETRO Yaltirik, 2011 RETRO 0.050 0.002 0.558 -1.815 0.070 Fixed RETRO 0.041 0.031 0.053 -22.950 0.000 Fixed Overall 0.057 0.049 0.065 -36.776 0.000
-0.25
-0.13
0.00
0.13
0.25
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
47RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual Failure rate- FPD cemented
Model Group by
Subgroup within study
Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
Favours A Favours B
Annual Survival rate- FPD cemented
Model Group by Subgroup within study
Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
CCT Gunne, 1999 CCT 0.011 0.001 0.151 -3.172 0.002 CCT Linkevicius, 2009 CCT 0.056 0.003 0.505 -1.947 0.052 CCT N issan, 2011 CCT 0.031 0.005 0.167 -3.680 0.000 Fixed CCT 0.028 0.007 0.099 -5.165 0.000 PROS Akca, 2008 PROS 0.038 0.009 0.146 -4.321 0.000 PROS Bragger 2005 PROS 0.051 0.012 0.195 -3.809 0.000 PROS Halg, 2008 PROS 0.009 0.001 0.129 -3.302 0.001 PROS Kourtis, 2004 PROS 0.011 0.002 0.054 -5.479 0.000 PROS Mertens, 2011 PROS 0.167 0.010 0.806 -1.039 0.299 PROS Pozzi, 2012 PROS 0.013 0.001 0.178 -3.033 0.002 PROS Romeo 2006 PROS 0.007 0.000 0.187 -2.777 0.005 PROS Schwarz, 2012 PROS 0.177 0.127 0.243 -7.549 0.000 Fixed PROS 0.121 0.088 0.164 -11.019 0.000 RCT Andersson 2003 RCT 0.054 0.008 0.295 -2.823 0.005 RCT Larsson, 2010 RCT 0.152 0.057 0.348 -3.086 0.002 RCT Pistilli 2013 RCT 0.012 0.001 0.167 -3.088 0.002 Fixed RCT 0.096 0.041 0.209 -4.847 0.000 RETRO Krennmair, 2010 RETRO 0.046 0.015 0.131 -5.241 0.000 RETRO Krennmair, 2011 RETRO 0.053 0.013 0.194 -3.879 0.000 RETRO Singer, 1996 RETRO 0.090 0.046 0.168 -6.351 0.000 RETRO Vanlioglu, 2013 RETRO 0.006 0.000 0.324 -2.287 0.022 RETRO Yaltirik, 2011 RETRO 0.024 0.001 0.287 -2.594 0.009 Fixed RETRO 0.066 0.039 0.108 -9.574 0.000 Fixed Overall 0.096 0.075 0.123 -15.979 0.000
-0.25
-0.13
0.00
0.13
0.25
Favours A Favours B
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
48RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual survivall rate- splintedcrowns cemented
Model Group by
Subgroup within study
Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper
rate limit limit Z-Value p-Value
CCT Linkevicius, 2009 CCT 0.019 0.001 0.236 -2.781 0.005
Fixed CCT 0.019 0.001 0.236 -2.781 0.005
Random CCT 0.019 0.001 0.236 -2.781 0.005
PROS Grandi, 2012 PROS 0.017 0.001 0.223 -2.834 0.005
PROS Kourtis, 2004 PROS 0.023 0.010 0.051 -8.687 0.000
Fixed PROS 0.022 0.010 0.048 -9.136 0.000
Random PROS 0.022 0.010 0.048 -9.136 0.000
RCT Cannizzaro, 2013 RCT 0.031 0.004 0.191 -3.380 0.001
Fixed RCT 0.031 0.004 0.191 -3.380 0.001
Random RCT 0.031 0.004 0.191 -3.380 0.001
RETR Vanlioglu, 2013 RETR 0.011 0.000 0.480 -1.996 0.046
Fixed RETR 0.011 0.000 0.480 -1.996 0.046
Random RETR 0.011 0.000 0.480 -1.996 0.046
Fixed Overall 0.022 0.011 0.045 -10.314 0.000
Random Overall 0.022 0.011 0.045 -10.314 0.000
-0.25 -0.13 0.00 0.13 0.25
Annual failurerate- cantilever FPD cemented
Model Group by
Subgroup within study
Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
pros Bischof, 2006 pros 0.005 0.000 0.299 -2.335 0.020 Fixed pros 0.005 0.000 0.299 -2.335 0.020
Random pros 0.005 0.000 0.299 -2.335 0.020 retro Halg, 2008 retro 0.014 0.001 0.261 -2.596 0.009 retro Kourtis, 2004 retro 0.014 0.001 0.191 -2.973 0.003 retro Palmer 2005 retro 0.025 0.002 0.298 -2.558 0.011 retro Beckerr 2004 retro 0.009 0.001 0.129 -3.302 0.001
Fixed retro 0.015 0.003 0.059 -5.724 0.000 Random retro 0.015 0.003 0.059 -5.724 0.000
Fixed Overall 0.013 0.003 0.050 -6.165 0.000 Random Overall 0.013 0.003 0.050 -6.165 0.000
-0.50
-0.25
0.00
0.25
0.50
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
49RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Annual SURVIVAL rate- cantilever FPD cemented
Model Group by
Subgroup within study
Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
pros Bischof, 2006 pros 0.041 0.009 0.172 -3.904 0.000 Fixed pros 0.041 0.009 0.172 -3.904 0.000
Random pros 0.041 0.002 0.470 -2.038 0.042 retro Halg, 2008 retro 0.056 0.011 0.234 -3.374 0.001 retro Kourtis, 2004 retro 0.038 0.007 0.187 -3.608 0.000 retro Palmer 2005 retro 0.281 0.125 0.515 -1.843 0.065 retro Beckerr 2004 retro 0.006 0.000 0.168 -2.833 0.005
Fixed retro 0.126 0.063 0.233 -5.067 0.000 Random retro 0.068 0.015 0.267 -3.198 0.001
Fixed Overall 0.103 0.055 0.185 -6.251 0.000 Random Overall 0.061 0.016 0.212 -3.779 0.000
-0.50
-0.25
0.00
0.25 0.50
Annual Failurel rate- splintedcrowns cemented
Model Group by
Subgroup within study
Study name Subgroup within study Statistics for each study Event rate and 95% CI
Event Lower Upper rate limit limit Z-Value p-Value
CCT Linkevicius, 2009 CCT 0.019 0.001 0.236 -2.781 0.005
Fixed CCT 0.019 0.001 0.236 -2.781 0.005
Random CCT 0.019 0.001 0.270 -2.617 0.009
PROS Grandi, 2012 PROS 0.017 0.001 0.223 -2.834 0.005
PROS Kourtis, 2004 PROS 0.002 0.000 0.032 -4.365 0.000
Fixed PROS 0.006 0.001 0.041 -5.095 0.000
Random PROS 0.006 0.001 0.046 -4.791 0.000
RCT Cannizzaro, 2013 RCT 0.025 0.003 0.191 -3.236 0.001
Fixed RCT 0.025 0.003 0.191 -3.236 0.001
Random RCT 0.025 0.002 0.227 -2.947 0.003
RETR Vanlioglu, 2013 RETR 0.026 0.002 0.310 -2.519 0.012
Fixed RETR 0.026 0.002 0.310 -2.519 0.012
Random RETR 0.026 0.001 0.348 -2.372 0.018
Fixed Overall 0.014 0.004 0.045 -7.018 0.000
Random Overall 0.014 0.004 0.050 -6.438 0.000
-0.25 -0.13 0.00 0.13 0.25
4.5:Economicanalysis:
The total initialcost for IS-Singlecrown is 4608.06$and$9816.08 for3unit IS-FPD
includingthelabcost.Thecostthataccountsformaintenance[minoradjustmentormajor
replacement]weretabulatedintable-16.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
50RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Table-16.Cost
Type&design
Initialcost[$]
Minorcomplicationcharges[$]
Majorcomplicationcharges[$]
Totalcost
Effectiveness[Eventfreerate%]
Singlecrown-Cemented
4608.06 224.15 2305.64 5339.03 60.5
Singlecrown-screwretained
4608.06 322.94 935.68 5244.44 45.5
FPD-Cemented
9816.08 448.30 5848.18 11406.67 62.4
FPD-Screwed
9816.08 645.84 1770.40 10819.43 43.5
The 15 year calculated cumulativeminor andmajor complication eventswere used as
probabilitytocalculatethetotalcostsofeachrestoration.[Minor:71.2%-screwretained
singlecrown,39.9%cementsinglecrown,63.94%screwFPD,36.23%CementFPD.Major:
43.44%Screwretainedsinglecrown,25.91%cementretainedsinglecrown,47.5%screw
FPD, 20.14% Cement FPD]. Annexure-7 is used to interpret the results of the cost
effectiveness.
5. Discussion.5.1. Summaryofclinicalevidence:
This report was undertaken to help dental practitioner to take evidence based
decision on choosing the retention system for implant supported prosthesis. To our
knowledge,thisisthefirstofsuchreportsonretentionsystemsusedforIS-prosthesis.This
reportaddressesthefailure,complicationrates,eventfreerateofIS-prosthesisinpartially
edentulouspatients.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
51RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Allofthe104studiesreportedonfailure,complicationeventswereseparatedbased on
theretentionsystem.Theestimatedfailurerate/100prosthesisyearisinrangeof 0.3%-
1.8%[1.3-1.8forsinglecrown,1.3-1.6 forsplintedcrowns,0.3-1.3forcantileverFPDs,1.4-
1.5 forFPDs].Table-17comprehensivelysummarizesthefailurerate,survivalratefor the
differentretentionsystems,differentprosthesisdesign,differentabutmentandprosthesis
material for 15 years. 15 years were chosen because most of the restorative dental
materialshave lifespanof10-15years.Tocomparethecostsandeffectsof screwand
cementretention,ICERratioisused.Meancosteffectivenessratioswerecalculated[mean
costdividebymeaneffectiveness].ICERratioforcementvsscrewis6.304forsinglecrown
and30.5forFPD.ICERSlopesforsinglecrownsandFPDareshowninfigures4and5.The
credibilityoftheresultsdependsontheassumptionsanddata.
Our findings suggest that Cement retainedprosthesis performwell compared to other
retentionsystemexceptforcantileverFPD.Theresultsofourreviewisinagreementwith
theprevioussystematicreviews39-53
- Weber2007 :Estimatedevent freerate/100prosthesisyearfor IS-Single
crown[cement-95.6%,screw-90.9%].
- Pjetursson2012:failurerateofIS-FPD.4.4%after5yearsand6.9%after10
yearscomparabletothepresentresult4.2%after5yearsand6.8%after 10
years.
- Aglieta2009:annualfailurerateofcantileverFPD1.18,whichiscomparable
tothe1.4%inthisreport.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
52RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
- Weber2007,Sailer2012;higherminorcomplicationeventsof screw
retentioncomparedtocementones.
- Wittenben2014reportedfailurerateofscrewIS-Sas1.85%[0.65;5.29] in
theirreview,thisisinagreementtothe1.8%[1.1;3.1]inthisreport.
Fig-4:ICERSlopesforsinglecrowns
Fig-5:ICERSlopesforFPD
53Table17:Estimatedfailurerate,survivalrate
Variables Retention type Failure
rate[%] 5 yr failure rate
10 yr failure arte
15 yr failure arte
Survival rate
5 yr survival rate
10 yr survival arte
15 yr survival arte
Single crown Cement Screw Mechano-chemical
1.3 1.8 1.4
2.5 3.5 1.59
3.5 3.7 3.1
4.4 3.8 4.5
4.2 8.5 7.8
14.5 26.6 31.3
25.5 42 54.3
35.1 50.7 67.8
Splinted crown Cement Screw
1.3 1.6
2.1 2.5
2.4 2.6
2.6 2.7
6.1 5.6
6.6 23.5
9.4 41.8
11.7 56.1
Cantilever FPD Cement Screw
1.4 0
3.1 0
3.9 0
4.4 0
2.2 4.3
12.8 12.5
20.4 18.7
24.5 78.9
FPD Cement Screw
1.4 1.5
4.2 3
6.8 3.5
8.6 3.9
4.5 7.7
12.8 21
21.3 32.6
29 42.6
Titanium Abutment
Cement Screw
0.2 0
0.99 0
1.98 0
2.95 0
2.8 0
13.06 0
24.42 0
34.29 0
Ceramic abutment
Cement Screw
0.2 0
0.99 0
1.98 0
2.95 0
0.2 0
0.99 0
1.98 0
2.9 0
PFM Cement Screw
0.3 0.1
1.4 0.5
2.95 0.99
4.4 1.48
4.1 5.9
18.53 25.54
33.63 44.56
45.93 58.72
All-Ceramic Cement Screw
0.2 0
0.9 0
1.98 0
2.95 0
2.7 4.4
19.74 11.75
22.11 58.10
31.27 72.28
Internal Hex Cement Screw
0.4 0
1.9 0
3.9 0
5.8 0
2.5 8.7
35.27 27.74
47.79 50.83
62.28 65.52
External hex Cement Screw
0.6 3.6
2.9 16.4
5.8 30.2
8.6 41.72
6.5 7.1
27.74 29.98
47.79 50.83
62.28 65.5
Anterior Cement Screw
0.4 0
1.98 0
3.9 0
5.8 0
11.4 7.6
43.44 31.61
68.01 53.23
81.91 68.01
Posterior Cement Screw
0.7 0.9
3.4 4.4
6.7 8.6
9.9 12.6
33.2 4.24
80.98 19.1
96.38 34.57
99.31 47.05
54
5.2. Ethicalandlegalconsiderations
Wedidnot identifyany literaturepertainingtoethical, social,socio-politicaland
legalissuesrelatedtoretentionsystemsusedforimplantsupportedreconstructions.Thus,
we are unable to report any such risks associatedwith the use of different retention
systems.Nonetheless,onthebasisofincludedstudieswecanconfirmthatscrewretained,
cementretainedsinglecrown,splintedcrown,cantileverFPD,FPDandmechano-chemical
retainedsinglecrownsaregloballyinuse.
5.3. Strengthandlimitations.
5.3.1. Strength
1. Themajor strengthof this report is the inclusionof16RCT’s;no systematic
reviewsareavailablewithmorethan6RCTssofar.
2. Intenseliteraturesearch:Thesystematicreviewwasconductedaccordingtoa
prespecifiedprotocol,usingstandardapproachforcollectingevidence, data
extraction,qualityassessmentandanalysis.
3. Thesystematicreviewincludedthreeretentionsystems;thisisthefirstreport
thatcomprehensivelyaddressesdifferentretentionsystemsusedinIS- partial
reconstructions.
4. Evidencewasanalyzedandpresentedusingmeta-analysisandMetaregression.
Robustness ofmeta-analysis findings is supportedby similarity between the
findingsofthisreportandpreviouslyreportedsystematicreviews.
55
RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
5. Addresstheheterogeneityindefiningthesuccessoutcomebyincluding event
freeasanoutcome.
5.3.2. Limitations:
1. Themajorityofthestudiesdidnotdifferentiatebetweenthetypesofabutment
material,prostheticmaterial,lutingagentsthuslimitingthenumberofstudies to
beincludedinsubgroupanalysis.
2. One of the major shortcoming was the inclusion of both prospective and
retrospectivestudieswhichlimitstheexternalvalidity.
3. Mostof the studieswereconducted in the institutionalenvironment [university
setting],whichlimitsthegeneralizabilityoftheresults.
4. ThecostanalysiswasdonefromanorthAmericanperspective[inUS$],however
thecostmayvarybetweendifferentregionsandthisanalysisisintendedonly to
providearoughestimatetothecliniciansnotanexhaustiveeconomicanalysis.
Thefollowingsuggestionsweremadebasedonourinference
- Improvingthereportingofstudyfindingsinliteratureswithcomprehensive
informationonretentionsystems,prosthesisdesign,abutmentdesign and
material.
- Design prospective comparison trials to evaluate the different retention
systemwitheconomicevaluationasoneoftheoutcome.
56
RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
6. Conclusion:
The objective of this report was to assess the effectiveness of different retention
systems and to determine the cost effectiveness of retention systems used for treating
partially edentulous patient with IS- prosthesis. Results from the systematic review
and meta-analysis suggest that there were no statistically significant differences in
failure rates between the retention systems and the prosthesis design. However the
survival rate was better with cement retained single crown and FPD. There were no
differences between major events but statistically significant differences with minor
events. In conclusion, within the limitations of this review cement retained prosthesis
fared better than the screw retained single crown and FPDs in relation to cost
effectiveness.
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
57
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103. Zembic, A., Bosch, A., Jung, R. E., Hammerle, C. H. & Sailer, I. (2013) Five-year results of a randomized controlled clinical trial comparing zirconia and titanium abutments supporting single-implant crowns in canine and posterior regions. Clinical Oral Implants Research 24, 384-390.
104. Zembic, A., Johannesen, L. H., Schou, S., Malo, P., Reichert, T., Farella, M. & Hammerle, C. H. (2012) Immediately restored one-piece single-tooth implants with reduced diameter: one-year results of a multi-center study. Clinical Oral
Implants Research 23, 49-54.
Excluded (based on quality score- weak)
• Canullo L. Clinical outcome study of customized zirconia abutments for single- implant restorations. International Journal of Prosthodontics. 2007;20(5):489-93.
• Eliasson A, Eriksson T, Johansson A, Wennerberg A. Fixed partial prostheses supported by 2 or 3 implants: A retrospective study up to 18 years. International Journal of Oral and Maxillofacial Implants. 2006;21(4):567-74.
• Froum SJ, Cho SC, Cho YS, Elian N, Tarnow D. Narrow-diameter implants: a restorative option for limited interdental space. International Journal of Periodontics & Restorative Dentistry. 2007;27(5):449-55.
• Knauf M, Gerds T, Muche R, Strub JR. Survival and success rates of 3i implants in partially edentulous patients: results of a prospective study with up to 84-months' follow-up. Quintessence International. 2007;38(8):643-51.
• Levine RA, Clem D, Beagle J, Ganeles J, Johnson P, Solnit G, et al. Multicenter retrospective analysis of the solid-screw ITI implant for posterior single- tooth replacements. The International journal of oral & maxillofacial implants. 2002;17(4):550-6.
• Levine RA, Clem DS, 3rd, Wilson TG, Jr., Higginbottom F, Solnit G. Multicenter retrospective analysis of the ITI implant system used for
single-tooth replacements: results of loading for 2 or more years. The International journal of oral & maxillofacial implants. 1999;14(4):516-20.
• Linkevicius T, Vladimirovas E, Grybauskas S, Puisys A, Rutkunas V. Veneer fracture in implant-supported metal- ceramic restorations. Part I: Overall success rate and impact of occlusal guidance. Stomatologija / issued by public institution "Odontologijos studija" [et al]. 2008;10(4):133-9.
• Norton MR. Biologic and mechanical stability of single-tooth implants: 4- to 7-year follow-up. Clinical Implant Dentistry & Related Research. 2001;3(4):214-20.
• Nothdurft F, Pospiech P. Prefabricated zirconium dioxide implant abutments for single-tooth replacement in the posterior region: evaluation of peri-implant tissues and superstructures after 12 months of function. Clinical Oral Implants Research. 2010;21(8):857-65.
Excluded articles 1. Abad-Gallegos M, Gomez-Santos L, Sanchez-Garces MA, Pinera-Penalva M, Freixes-Gil J, Castro-Garcia A, et al. Complications of guided surgery and immediate loading in oral implantology: A report of 12 cases. Medicina Oral, Patologia Oral y Cirugia Bucal. 2011;16(2):e220-e4. 2. Abboud M, Koeck B, Stark H, Wahl G, Paillon R. Immediate loading of single-tooth implants in the posterior region. The International journal of oral & maxillofacial implants. 2005;20(1):61-8. 3. Aglietta M, Siciliano VI, Zwahlen M, Brägger U, Pjetursson BE, Lang NP, et al. A systematic review of the survival and complication rates of implant supported fixed dental prostheses with cantilever extensions after an observation period of at least 5 years. Clinical oral implants research. 2009;20(5):441-51. 4. Allen PF, McMillan AS, Smith DG. Complications and maintenance requirements of implant-supported prostheses provided in a UK dental hospital. British dental journal. 1997;182(8):298-302. 5. Andersson B, Odman P, Lindvall AM, Branemark PI. Five-year prospective study of prosthodontic and surgical single-tooth implant treatment in general practices and at a specialist clinic. The International journal of prosthodontics. 1998;11(4):351-5. 6. Andersson B, Taylor A, Lang BR, Scheller H, Scharer P, Sorensen JA, et al. Alumina ceramic implant abutments used for single-tooth replacement: a prospective 1- to 3-year multicenter study. The International journal of prosthodontics. 2001;14(5):432-8. 7. Astrand P, Engquist B, Anzen B, Bergendal T, Hallman M, Karlsson U, et al. A three-year follow-up report of a comparative study of ITI Dental Implants and Branemark System implants in the treatment of the partially edentulous maxilla. Clinical implant dentistry and related research. 2004;6(3):130-41. 8. Bahat O, Handelsman M. Use of wide implants and double implants in the posterior jaw: a clinical report. The International journal of oral & maxillofacial implants.
1996;11(3):379-86. 9. Balshi TJ, Ekfeldt A, Stenberg T, Vrielinck L. Three-year evaluation of Branemark implants connected to angulated abutments. The International journal of oral & maxillofacial implants. 1997;12(1):52-8. 10. Barrachina-Diez JM, Tashkandi E, Stampf S, Att W. Long-term outcome of one-piece implants. Part II: Prosthetic outcomes. A systematic literature review with meta-analysis. International Journal of Oral & Maxillofacial Implants. 2013;28(6):1470-82. 11. Behneke A, Behneke N, d'Hoedt B, Wagner W. Hard and soft tissue reactions to ITI screw implants: 3-year longitudinal results of a prospective study. International Journal of Oral & Maxillofacial Implants. 1997;12(6):749-57. 12. Behr M, Lang R, Leibrock A, Rosentritt M, Handel G. Complication rate with prosthodontic reconstructions on ITI and IMZ dental implants. Internationales Team fur Implantologie. Clinical oral implants research. 1998;9(1):51-8 13. Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. Journal of clinical periodontology. 2002;29 Suppl 3:197-212; discussion 32-33. 14. Bianco G, Di Raimondo R, Luongo G, Paoleschi C, Piccoli P, Piccoli C, et al. Osseointegrated implant for single-tooth replacement: a retrospective multicenter study on routine use in private practice. Clinical Implant Dentistry & Related Research. 2000;2(3):152-8. 15. Bidra AS, Rungruanganunt P. Clinical Outcomes of Implant Abutments in the Anterior Region: A Systematic Review. Journal of Esthetic and Restorative Dentistry. 2013;25(3):159-76. 16. Block MS, Gardiner D, Kent JN, Misiek DJ, Finger IM, Guerra L. Hydroxyapatite-coated cylindrical implants in the posterior mandible: 10-year observations. The International journal of oral & maxillofacial implants. 1996;11(5):626-33. 17. Block MS, Lirette D, Gardiner D, Li L, Finger IM, Hochstedler J, et al. Prospective
evaluation of implants connected to teeth. The International journal of oral & maxillofacial implants. 2002;17(4):473-87. 18. Bornstein MM, Chappuis V, von Arx T, Buser D. Performance of dental implants after staged sinus floor elevation procedures: 5-year results of a prospective study in partially edentulous patients. Clinical oral implants research. 2008;19(10):1034-43. 19. Bornstein MM, Schmid B, Belser UC, Lussi A, Buser D. Early loading of non-submerged titanium implants with a sandblasted and acid-etched surface. 5-year results of a prospective study in partially edentulous patients. Clinical oral implants research. 2005;16(6):631-8. 20. Bornstein MM, Wittneben JG, Bragger U, Buser D. Early loading at 21 days of non-submerged titanium implants with a chemically modified sandblasted and acid-etched surface: 3-year results of a prospective study in the posterior mandible. Journal of periodontology. 2010;81(6):809-18. 21. Bragger U, Aeschlimann S, Burgin W, Hammerle CH, Lang NP. Biological and technical complications and failures with fixed partial dentures (FPD) on implants and teeth after four to five years of function. Clinical oral implants research. 2001;12(1):26-34. 22. Bragger U, Hirt-Steiner S, Schnell N, Schmidlin K, Salvi GE, Pjetursson B, et al. Complication and failure rates of fixed dental prostheses in patients treated for periodontal disease. Clinical oral implants research. 2011;22(1):70-7 23. Brocard D, Barthet P, Baysse E, Duffort JF, Eller P, Justumus P, et al. A multicenter report on 1,022 consecutively placed ITI implants: a 7-year longitudinal study. International Journal of Oral & Maxillofacial Implants. 2000;15(5):691-700. 24. Buser D, Janner SFM, Wittneben J-G, Brägger U, Ramseier CA, Salvi GE. 10-Year Survival and Success Rates of 511 Titanium Implants with a Sandblasted and Acid-Etched Surface: A Retrospective Study in 303 Partially Edentulous Patients. Clinical implant dentistry and related research.
2012;14(6):839-51. 25. Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke N, Hirt HP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clinical oral implants research. 1997;8(3):161-72. 26. Buser D, Weber HP, Bragger U, Balsiger C. Tissue integration of one-stage implants: three-year results of a prospective longitudinal study with hollow cylinder and hollow screw implants. Quintessence international (Berlin, Germany : 1985). 1994;25(10):679-86. 27. Buser D, Weber HP, Lang NP. Tissue integration of non-submerged implants. 1-year results of a prospective study with 100 ITI hollow-cylinder and hollow-screw implants. Clinical oral implants research. 1990;1(1):33-40. 28. Cannizzaro G, Felice P, Leone M, Checchi V, Esposito M. Flapless versus open flap implant surgery in partially edentulous patients subjected to immediate loading: 1-year results from a split-mouth randomised controlled trial. European journal of oral implantology. 2011;4(3):177-88. 29. Capelli M, Esposito M, Zuffetti F, Galli F, Del Fabbro M, Testroi T. A 5-year report from a multicentre randomised clinical trial: immediate non-occlusal versus early loading of dental implants in partially edentulous patients. European journal of oral implantology. 2010;3(3):209-19. 30. Cecchinato D, Bengazi F, Blasi G, Botticelli D, Cardarelli I, Gualini F. Bone level alterations at implants placed in the posterior segments of the dentition: outcome of submerged/non-submerged healing. A 5-year multicenter, randomized, controlled clinical trial. Clinical oral implants research. 2008;19(4):429-31. 31. Chaar MS, Att W, Strub JR. Prosthetic outcome of cement-retained implant-supported fixed dental restorations: a systematic review. Journal of Oral Rehabilitation. 2011;38(9):697-711. 32. Chapman RJ, Grippo W. The locking
taper attachment for implant abutments: use and reliability. Implant dentistry. 1996;5(4):257-61. 33. Checchi L, Felice P, Antonini ES, Cosci F, Pellegrino G, Esposito M. Crestal sinus lift for implant rehabilitation: a randomised clinical trial comparing the Cosci and the Summers techniques. A preliminary report on complications and patient preference. European journal of oral implantology. 2010;3(3):221-32. 34. Cicciù M, Beretta M, Risitano G, Maiorana C. Cemented-retained vs screw-retained implant restorations: an investigation on 1939 dental implants. Minerva stomatologica. 2008;57(4):167-79. 35. Cochran DL, Jackson JM, Jones AA, Jones JD, Kaiser DA, Taylor TD, et al. A 5-year prospective multicenter clinical trial of non-submerged dental implants with a titanium plasma-sprayed surface in 200 patients. Journal of periodontology. 2011;82(7):990-9. 36. Cochran DL, Nummikoski PV, Schoolfield JD, Jones AA, Oates TW. A prospective multicenter 5-year radiographic evaluation of crestal bone levels over time in 596 dental implants placed in 192 patients. Journal of periodontology. 2009;80(5):725-33. 37. Cooper L, Felton DA, Kugelberg CF, Ellner S, Chaffee N, Molina AL, et al. A multicenter 12-month evaluation of single-tooth implants restored 3 weeks after 1-stage surgery. The International journal of oral & maxillofacial implants. 2001;16(2):182-92 38. Cosyn J, van Aelst L, Collaert B, Persson GR, de Bruyn H. The peri-implant sulcus compared with internal implant and suprastructure components: A microbiological analysis. Clinical implant dentistry and related research. 2011;13(4):286-95. 39. Crespi R, Cappare P, Gherlone E. Osteotome sinus floor elevation and simultaneous implant placement in grafted biomaterial sockets: 3 years of follow-up. Journal of periodontology. 2010;81(3):344-9. 40. Creugers NH, Kreulen CM, Snoek PA,
de Kanter RJ. A systematic review of single-tooth restorations supported by implants. Journal of dentistry. 2000;28(4):209-17 41. Davarpanah M, Martinez H, Tecucianu JF, Alcoforado G, Etienne D, Celletti R. The self-tapping and ICE 3i implants: a prospective 3-year multicenter evaluation. International Journal of Oral & Maxillofacial Implants. 2001;16(1):52-60. 42. De Boever AL, De Boever JA. Guided bone regeneration around non-submerged implants in narrow alveolar ridges: a prospective long-term clinical study. Clinical oral implants research. 2005;16(5):549-56. 43. De Boever AL, Quirynen M, Coucke W, Theuniers G, De Boever JA. Clinical and radiographic study of implant treatment outcome in periodontally susceptible and non-susceptible patients: a prospective long-term study. Clinical oral implants research. 2009;20(12):1341-50. 44. De Brandao ML, Vettore MV, Vidigal Junior GM. Peri-implant bone loss in cement- and screw-retained prostheses: Systematic review and meta-analysis. Journal of Clinical Periodontology. 2013;40(3):287-95. 45. De la Rosa M, Rodriguez A, Sierra K, Mendoza G, Chambrone L. Predictors of peri-implant bone loss during long-term maintenance of patients treated with 10-mm implants and single crown restorations. The International journal of oral & maxillofacial implants. 2013;28(3):798-802. 46. De Leonardis D, Garg AK, Pecora GE. Osseointegration of rough acid-etched titanium implants: 5-year follow-up of 100 minimatic implants. International Journal of Oral & Maxillofacial Implants. 1999;14(3):384-91. 47. De Rouck T, Collys K, Cosyn J. Immediate single-tooth implants in the anterior maxilla: a 1-year case cohort study on hard and soft tissue response. Journal of Clinical Periodontology. 2008;35(7):649-57. 48. Degidi M, Piattelli A, Carinci F. Parallel screw cylinder implants: comparative analysis between immediate loading and two-stage healing of 1,005 dental implants with a 2-year follow up. Clinical Implant Dentistry & Related Research. 2006;8(3):151-60.
49. Deporter DA, Todescan R, Watson PA, Pharoah M, Levy D, Nardini K. Use of the Endopore dental implant to restore single teeth in the maxilla: protocol and early results. The International journal of oral & maxillofacial implants. 1998;13(2):263-72. 50. D'Haese J, Vervaeke S, Verbanck N, De Bruyn H. Clinical and radiographic outcome of implants placed using stereolithographic guided surgery: a prospective monocenter study. The International journal of oral & maxillofacial implants. 2013;28(1):205-15. 51. Di Alberti L, Di Alberti C, Donini F, Lo ML, Cadrobbi F, D'Agostino A, et al. Clinical and mechanical evaluation of screw-retained implant-supported zirconia restorations. A 36 months prospective clinical study. Minerva stomatologica. 2013. 52. Dierens M, Vandeweghe S, Kisch J, Nilner K, De Bruyn H. Long-term follow-up of turned single implants placed in periodontally healthy patients after 16-22 years: radiographic and peri-implant outcome. Clinical oral implants research. 2012;23(2):197-204. 53. Draenert FG, Sagheb K, Baumgardt K, Kammerer PW. Retrospective analysis of survival rates and marginal bone loss on short implants in the mandible. Clinical oral implants research. 2012;23(9):1063-9. 54. Duncan JP, Nazarova E, Vogiatzi T, Taylor TD. Prosthodontic complications in a prospective clinical trial of single-stage implants at 36 months. The International journal of oral & maxillofacial implants. 2003;18(4):561-5. 55. Eckert SE, Meraw SJ, Cal E, Ow RK. Analysis of incidence and associated factors with fractured implants: a retrospective study. International Journal of Oral & Maxillofacial Implants. 2000;15(5):662-7. 56. Eckert SE, Wollan PC. Retrospective review of 1170 endosseous implants placed in partially edentulous jaws. Journal of Prosthetic Dentistry. 1998;79(4):415-21. 57. Ekfeldt A, Carlsson GE, Borjesson G. Clinical evaluation of single-tooth restorations supported by osseointegrated implants: a
retrospective study. The International journal of oral & maxillofacial implants. 1994;9(2):179-83. 58. Ekfeldt A, Furst B, Carlsson GE. Zirconia abutments for single-tooth implant restorations: a retrospective and clinical follow-up study. Clinical oral implants research. 2011;22(11):1308-14. 59. Elkhoury JS, McGlumphy EA, Tatakis DN, Beck FM. Clinical parameters associated with success and failure of single-tooth titanium plasma-sprayed cylindric implants under stricter criteria: a 5-year retrospective study. The International journal of oral & maxillofacial implants. 2005;20(5):687-94. 60. Esposito M, Cannizzaro G, Soardi E, Pistilli R, Piattelli M, Corvino V, et al. Posterior atrophic jaws rehabilitated with prostheses supported by 6 mm-long, 4 mm-wide implants or by longer implants in augmented bone. Preliminary results from a pilot randomised controlled trial. European journal of oral implantology. 2012;5(1):19-33. 61. Felice P, Pistilli R, Piattelli M, Soardi E, Corvino V, Esposito M. Posterior atrophic jaws rehabilitated with prostheses supported by 5 x 5 mm implants with a novel nanostructured calcium-incorporated titanium surface or by longer implants in augmented bone. Preliminary results from a randomised controlled trial. European journal of oral implantology. 2012;5(2):149-61. 62. Fugazzotto PA, Vlassis J, Butler B. ITI implant use in private practice: clinical results with 5,526 implants followed up to 72+ months in function. The International journal of oral & maxillofacial implants. 2004;19(3):408-12. 63. Fung K, Marzola R, Scotti R, Tadinada A, Schincaglia GP. A 36-month randomized controlled split-mouth trial comparing immediately loaded titanium oxide-anodized and machined implants supporting fixed partial dentures in the posterior mandible. The International journal of oral & maxillofacial implants. 2011;26(3):631-8. 64. Gallucci GO, Grutter L, Nedir R, Bischof M, Belser UC. Esthetic outcomes with porcelain-fused-to-ceramic and all-ceramic single-implant crowns: A randomized clinical
trial. Clinical oral implants research. 2011;22(1):62-9. 65. Gibbard LL, Zarb G. A 5-year prospective study of implant-supported single-tooth replacements. Journal (Canadian Dental Association). 2002;68(2):110-6. 66. Gomez-Roman G, Schulte W, d'Hoedt B, Axman-Krcmar D. The Frialit-2 implant system: five-year clinical experience in single-tooth and immediately postextraction applications. The International journal of oral & maxillofacial implants. 1997;12(3):299-309. 67. Goodacre CJ, Kan JY, Rungcharassaeng K. Clinical complications of osseointegrated implants. Journal of Prosthetic Dentistry. 1999;81(5):537-52. 68. Gotfredsen K. A 5-year prospective study of single-tooth replacements supported by the Astra Tech implant: a pilot study. Clinical implant dentistry and related research. 2004;6(1):1-8. 69. Gotfredsen K, Wiskott A, Gracis S, Heydecke G, Sailer I, Roccuzzo M, et al. Consensus report - reconstructions on implants. The Third EAO Consensus Conference 2012. Clinical oral implants research. 2012;23(SUPPL.6):238-41. 70. Gothberg C, Bergendal T, Magnusson T. Complications after treatment with implant-supported fixed prostheses: a retrospective study. The International journal of prosthodontics. 2003;16(2):201-7. 71. Gracis S, Michalakis K, Vigolo P, Vult von Steyern P, Zwahlen M, Sailer I. Internal vs. external connections for abutments/reconstructions: A systematic review. Clinical oral implants research. 2012;23(SUPPL.6):202-16. 72. Groisman M, Ferreira HM, Frossard WM, de Menezes Filho LM, Harari ND. Clinical evaluation of hydroxyapatite-coated single-tooth implants: a 5-year retrospective study. Practical procedures & aesthetic dentistry : PPAD. 2001;13(5):355-60; quiz 62. 73. Gultekin P, Gultekin BA, Aydin M, Yalcin S. Cement Selection for Implant-Supported Crowns Fabricated with Different Luting Space Settings. Journal of
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ii
Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.
Annexe-1BasicCharacteristicstable-Prioriform
No
Retentiontype
Studydesign
Quality
score
NoofPatients
Agerange
NoofImplants
Noofprosthe
sis
Prosthesis
design
Observation
period
Dropouts
Studysetting
M F T
Annexure-2:Prioriform
RCT CCT
Prospective Retrospectiveee
Strong Medium Weak
Ref: Screwed Cemented/IAC Total patient: M
F No of Implants No of Single crowns
No of FPDS No of Splinted crowns
No of T-IS FPD No of cantilever FPD
No of fs-FPD Brand name
PFM/PBM PFG
All ceramic Resin
Custom abutment Prefabricated
Observation period Mean observation
Total lost to follow up Lost due to failure
Minor porcelain chip occlusal/prosthetic screw loosening
Abutment screw loosening
Re cementation
crown loosening Prosthetic/occlusal screw fracture
Abutment screw fracture
abutment fracture
Crown remade Minor biological events
Major biological events Total Failure
At the start: Finalfollowup:
Total Minor : TotalMajor:
Without events: Survival:
21
Maxilla-
Mandible-
Anterior-
Posterior- Any other in results: Titanium Screw- Gold Screw-
Cement type-
Screw access hole-
Occlusal material to cover- Other:
i
Annexe-3.Criticalappraisaltool
Reference Studydomain Strong[1] Moderate[2] Weak[3]
SelectionBias
StudyDesign
Confounders
Blinding
DataCollection
Withdrawalsand
dropout
Finalratingofthearticle
Strong[Noweakratings]inanyofthedomains
Moderate[oneweakrating]
Weak[Twoormoreweakrating]
Annexe-4:Formulasusedforcalculation
Failureratecalculation:
Nooffailure/totalprosthesisobservationtime=Failure rate.
FailurerateX100=Estimatedannualfailurerate/100prosthesis/year
5yearfailureproportion=1-exp(-5xfailurerate)
10yearfailureproportion=1-exp(-10xfailurerate)
15yearfailureproportion=1-exp(-15xfailurerate)
20yearfailureproportion=1-exp(-20xfailurerate)
25yearfailureproportion=1-exp(-25xfailurerate)
Survivalratecalculation:
Noofcomplicationevents=Minortechnicalevents+minorbiologicalevents+majortechnical
events+majorbiologicalevents
Noofcomplicationevents/totalprosthesisobservationtime=survivalrate.
SurvivalrateX100=Estimatedannualsurvivalrate/100prosthesis/year
5yearSurvivalproportion=1-exp(-5xsurvivalrate)
10yearSurvivalproportion=1-exp(-10xsurvivalrate)
15yearSurvivalproportion=1-exp(-15xsurvivalrate)
20yearSurvivalproportion=1-exp(-20xsurvivalrate)
25yearSurvivalproportion=1-exp(-25xsurvivalrate)
Eventfreeratecalculation:
Noofevents=complicationevents+failureevents
Noofevents/totalprosthesisobservationtime=event rate.
Eventfreerate=1-eventrate
EventfreerateX100=Estimatedannualeventfreerate/100prosthesis/year
5yearEventfreeproportion=exp(-5xfailurerate)
10yearEventfreeproportion=exp(-10xfailurerate)
15yearEventfreefailureproportion=exp(-15xfailurerate)
20yearEventfreefailureproportion=exp(-20xfailure rate)
25yearEventfreeproportion=exp(-25xfailurerate)
Annexure-5:ADAsurvey
Code Treatment Generaldentist Specialist
D0120 Periodicexamination 44.10 57.34
D0220 IOPA 25 26.41
D0431 Treatingmucosalabnormalities 61.84
D0470 Diagnosticcast 87.19
D1110 Prophylaxis 82.08 100.61
D2330 Resinbasedcomposite[1surface] 139.84
D2920 Crownrecementation 89.27 110.29
D6010 Implantsurgicalplacement 1741 2040.55
D6056 Prefabricatedabutmentincluding
placement
604.50 696.72
D6057 Customabutmentincluding
placement
760.93 880.85
D6059 PFGCrown 1246.11 1583.10
D6066 PFMcrown 1316.98 1709.84
D6080 Maintenance[screwreplacement,
reinsertion]
174.75 224.30
D6930 RecementationofFPD 133.78 163.67
D9120 Sectioningtheprosthesis 131.63
D9951 Adjustment 125.54 180.23
D9440 Afterscheduledhour 155.26
Annexure-6Meanhourlywage[USLaborstatistics]
Dentist 80.20
Dental
assistant
17.02
Dentallab
technician
19.69
Receptionist 15.62
Annexure-7:-Kappainterauthoragreement
Title & Abstract screening
Reviewer1
Yes No
Reviewer2 Yes 322 18
No 0 556
Number of observed agreements: 878 ( 97.99% of the observations)
Number of agreements expected by chance: 478.4 ( 53.39% of the observations)
Kappa= 0.957 SE of kappa = 0.010 95% confidence interval: From 0.937 to 0.977
Full Text evaluation:
Reviewer1
Yes No
Reviewer2 Yes 128 9
No 14 178
Number of observed agreements: 306 ( 93.01% of the observations)
Number of agreements expected by chance: 168.3 ( 51.14% of the observations)
Kappa= 0.857 SE of kappa = 0.029 95% confidence interval: From 0.801 to 0.913
Critical appraisal:
Reviewer1
Strong Moderate Weak
Reviewer2 Strong 17 2 0
Moderate 0 85 0
Weak 0 0 9
Number of observed agreements: 111 ( 98.23% of the observations)
Number of agreements expected by chance: 71.5 ( 63.27% of the observations)
Kappa= 0.952 SE of kappa = 0.034 95% confidence interval: From 0.886 to 1.000
Annexure-8: Meta regression
Regression of Rate on FAILURE
0.06
0.05
0.04
0.03
0.02
0.00
-0.01
-0.02
-0.03
-0.04
M C S
FAILURE
M-Mechano-chemical,C-Cement, S-Screw
Regression of Rate on FAILURE
0.06
0.05
0.04
0.03
0.02
0.00
-0.01
-0.02
-0.03
Y = 0.0127 - 0.0095 if FAILURE = C - 0.0083 if FAILURE = S
-0.04
M C S
FAILURE
M-Mechano-chemical,C-Cement, S-Screw
Regression of Rate on FAILURE[ABUTMENT TYPE]
0.05
0.04
0.03
0.02
0.01
-0.01
-0.02
-0.03
Y = 0.0099 - 0.0062 if FAILURE = SCR
-0.04
CEMENT SCREW
FAILURE
Regression of Rate on FAILURE[Implant-abutment connectionT TYPE]
0.06
0.05
0.04
0.03
0.01
0.00
-0.01
-0.02
Y = 0.0042 - 0.0027 if reteention failur
-0.03
cement screw
retention failure
R
ate
Regression of Rate on FAILURE[Prosthesis materialT TYPE]
0.01
0.01
0.01
0.01
0.00
0.00
0.00
0.00
Y = 0.0027 0.00 - 0.0018 if reteention failur
-0.01
cement screw
reteention failure
Regression of Rate on FAILURE[edentulous locationT TYPE]
0.01
0.01
0.01
0.00
0.00
0.00
0.00
0.00 Y = 0.0027 - 0.0008 if reteention failur
-0.01
cement screw
retention failure
Regression of Rate on survival-Prosthesis design
0.00
-0.50
-1.00
-1.50
-2.00
-2.50
-3.00
-3.50
-4.00
-4.50
-5.00
Y = -3.1763 + 0.8022 if Retention-Surv + 0.6259 if Retention-Surv + 0.6487 if Retention-Surv
C M S SC
Retention-Survival
C-Cantilever,M-FPD,s-Singlecrown,sc—Splintedcrown
Regression of Rate on FAILURE[Prosthesis materialT TYPE]
0.01
0.01
0.01
0.01
0.00
0.00
0.00
0.00
Y = 0.0027 0.00 - 0.0018 if reteention failur
-0.01
cement screw
reteention failure
Lo
git e
ve
nt r
ate
Regression of Rate on survival-Abutment material
25.00
20.00
15.00
10.00
5.00
0.00
-5.00
-10.00
-15.00
-20.00
-25.00
-30.00
Y = -5.2714 + 0.3345 if Retention-Surv
-35.00
ceramic ti
Retention-Survival
Regression of Rate on survival-Prosthesist material
0.00
-1.00
-2.00
-3.00
-4.00
-5.00
-6.00
Y = -3.4104 + 0.4580 if Retention-Surv
-7.00
ceramic PFM
Retention-Survival
Regression of Rate on survival-Implant abutment connection
6.00
4.00
2.00
0.00
-2.00
-4.00
-6.00
-8.00
-10.00
-12.00
Y = -3.3751 + 0.3755 if Retention-Surv
-14.00
external hex Internal hex
Retention-Survival
Annexure-9: Cost effectiveness ICER slope interpretation guidelines.
Annexure-10:[ICERCalculationforsinglecrown]
Recommended